Abstract
Background: During the COVID-19 pandemic many intensive care units have been overwhelmed by unprecedented levels of demand. Notwithstanding ethical considerations, the prioritisation of patients with better prognoses may support a more effective use of available capacity in maximising aggregate outcomes. This has prompted various proposed triage criteria, although in none of these has an objective assessment been made in terms of impact on number of lives and life-years saved.
Design: An open source computer simulation model was constructed for approximating the intensive care admission and discharge dynamics under triage. The model was calibrated from observational data for 9505 patient admissions to UK intensive care units. In order to explore triage efficacy under various conditions, scenario analysis was performed using a range of demand trajectories corresponding to differing non-pharmaceutical interventions.
Results: Triaging patients at the point of expressed demand had negligible effect on deaths but reduces life-years lost by up to 8.4% (95% CI: 2.6% to 18.7%). Greater value may be possible through ‘reverse triage’, i.e. promptly discharging any patient not meeting the criteria if admission cannot otherwise be guaranteed for one that does. Under such policy, life-years lost can be reduced by 11.7% (2.8% to 25.8%), which represents 23.0% (5.4% to 50.1%) of what is operationally feasible with no limit on capacity and in absence of improved clinical treatments.
Conclusions: The effect of simple triage is limited by a trade-off between reduced deaths within intensive care (due to improved outcomes) and increased deaths resulting from declined admission (due to lower throughput given the longer lengths of stay of survivors). Improvements can be found through reverse triage, at the expense of potentially complex ethical considerations.
Design: An open source computer simulation model was constructed for approximating the intensive care admission and discharge dynamics under triage. The model was calibrated from observational data for 9505 patient admissions to UK intensive care units. In order to explore triage efficacy under various conditions, scenario analysis was performed using a range of demand trajectories corresponding to differing non-pharmaceutical interventions.
Results: Triaging patients at the point of expressed demand had negligible effect on deaths but reduces life-years lost by up to 8.4% (95% CI: 2.6% to 18.7%). Greater value may be possible through ‘reverse triage’, i.e. promptly discharging any patient not meeting the criteria if admission cannot otherwise be guaranteed for one that does. Under such policy, life-years lost can be reduced by 11.7% (2.8% to 25.8%), which represents 23.0% (5.4% to 50.1%) of what is operationally feasible with no limit on capacity and in absence of improved clinical treatments.
Conclusions: The effect of simple triage is limited by a trade-off between reduced deaths within intensive care (due to improved outcomes) and increased deaths resulting from declined admission (due to lower throughput given the longer lengths of stay of survivors). Improvements can be found through reverse triage, at the expense of potentially complex ethical considerations.
| Original language | English |
|---|---|
| Pages (from-to) | 393-407 |
| Number of pages | 15 |
| Journal | Medical Decision Making |
| Volume | 41 |
| Issue number | 4 |
| Early online date | 9 Feb 2021 |
| DOIs | |
| Publication status | Published - 1 May 2021 |
Funding
This study was undertaken through the South West Better Care Partnership supported by Health Data Research UK. The authors are grateful to the anonymous reviewers and editorial team whose helpful comments and suggestions have improved the legibility and quality of this article.