A Framework for Rationing Ventilators and Critical Care Beds During the COVID-19 Pandemic
TL;DR: As the coronavirus disease 2019 (COVID-19) pandemic intensifies, shortages of ventilators have occurred in Italy and are likely imminent in parts of the US, raising a critical question: when demand for ventilator support far outstrips the supply, what criteria should guide these rationing decisions?
Abstract: As the coronavirus disease 2019 (COVID-19) pandemic intensifies, shortages of ventilators have occurred in Italy and are likely imminent in parts of the US. In ordinary clinical circumstances, all patients in need of mechanical ventilation because of potentially-reversible conditions receive it, unless they or their surrogates decline. However, there are mounting concerns in many countries that this will not be possible and that patients who otherwise would likely survive if they received ventilator support will die because no ventilator is available. In this type of public health emergency, the ethical obligation of physicians to prioritize the well-being of individual patients may be overridden by public health policies that prioritize doing the greatest good for the greatest number of patients.1 These circumstances raise a critical question: when demand for ventilators and other intensive treatments far outstrips the supply, what criteria should guide these rationing decisions? Existing recommendations for how to allocate scarce critical care resources during a pandemic or disaster contain ethically problematic provisions, such as categorically excluding large populations of patients from access to scarce intensive care unit (ICU) resources. This
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University of Warwick1, University of Nottingham Malaysia Campus2, London South Bank University3, Al-Hikmah University4, National University of Malaysia5, University of Nottingham6, University of Kent7, Kyushu University8, American University of Sharjah9, Birkbeck, University of London10, University of Sheffield11
TL;DR: In this paper, the authors present a critical review of negative and positive impacts of the pandemic and proffers perspectives on how it can be leveraged to steer towards a better, more resilient low carbon economy.
Abstract: The World Health Organization declared COVID-19 a global pandemic on the 11th of March 2020, but the world is still reeling from its aftermath. Originating from China, cases quickly spread across the globe, prompting the implementation of stringent measures by world governments in efforts to isolate cases and limit the transmission rate of the virus. These measures have however shattered the core sustaining pillars of the modern world economies as global trade and cooperation succumbed to nationalist focus and competition for scarce supplies. Against this backdrop, this paper presents a critical review of the catalogue of negative and positive impacts of the pandemic and proffers perspectives on how it can be leveraged to steer towards a better, more resilient low-carbon economy. The paper diagnosed the danger of relying on pandemic-driven benefits to achieving sustainable development goals and emphasizes a need for a decisive, fundamental structural change to the dynamics of how we live. It argues for a rethink of the present global economic growth model, shaped by a linear economy system and sustained by profiteering and energy-gulping manufacturing processes, in favour of a more sustainable model recalibrated on circular economy (CE) framework. Building on evidence in support of CE as a vehicle for balancing the complex equation of accomplishing profit with minimal environmental harms, the paper outlines concrete sector-specific recommendations on CE-related solutions as a catalyst for the global economic growth and development in a resilient post-COVID-19 world.
432 citations
Cites background from "A Framework for Rationing Ventilato..."
...For ventilators, in particular, frameworks for rationing them along with bed spaces have had to be developed to optimise their usage (White and Lo, 2020)....
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TL;DR: The results may help guide clinical management of severe COVID-19 patients, particularly in settings requiring strategic allocation of limited critical care resources, and hypoxemia was independently associated with in-hospital mortality.
408 citations
TL;DR: Projection of the number of COVID-19 cases and the associated burden on healthcare resources using a modified SEIR model reveals that rural regions in the United States are at risk of higher per capita case burdens, which could lead to health systems being overwhelmed in these areas.
Abstract: As of 24 April 2020, the SARS-CoV-2 epidemic has resulted in over 830,000 confirmed infections in the United States1. The incidence of COVID-19, the disease associated with this new coronavirus, continues to rise. The epidemic threatens to overwhelm healthcare systems, and identifying those regions where the disease burden is likely to be high relative to the rest of the country is critical for enabling prudent and effective distribution of emergency medical care and public health resources. Globally, the risk of severe outcomes associated with COVID-19 has consistently been observed to increase with age2,3. We used age-specific mortality patterns in tandem with demographic data to map projections of the cumulative case burden of COVID-19 and the subsequent burden on healthcare resources. The analysis was performed at the county level across the United States, assuming a scenario in which 20% of the population of each county acquires infection. We identified counties that will probably be consistently, heavily affected relative to the rest of the country across a range of assumptions about transmission patterns, such as the basic reproductive rate, contact patterns and the efficacy of quarantine. We observed a general pattern that per capita disease burden and relative healthcare system demand may be highest away from major population centers. These findings highlight the importance of ensuring equitable and adequate allocation of medical care and public health resources to communities outside of major urban areas.
347 citations
TL;DR: An early short course of methylprednisolone in patients with moderate to severe COVID-19 reduced escalation of care and improved clinical outcomes.
Abstract: BACKGROUND: There is no proven antiviral or immunomodulatory therapy for coronavirus disease 2019 (COVID-19). The disease progression associated with the proinflammatory host response prompted us to examine the role of early corticosteroid therapy in patients with moderate to severe COVID-19. METHODS: We conducted a single pretest, single posttest quasi-experiment in a multicenter health system in Michigan from 12 March to 27 March 2020. Adult patients with confirmed moderate to severe COVID were included. A protocol was implemented on 20 March 2020 using early, short-course, methylprednisolone 0.5 to 1 mg/kg/day divided in 2 intravenous doses for 3 days. Outcomes of standard of care (SOC) and early corticosteroid groups were evaluated, with a primary composite endpoint of escalation of care from ward to intensive care unit (ICU), new requirement for mechanical ventilation, and mortality. All patients had at least 14 days of follow-up. RESULTS: We analyzed 213 eligible subjects, 81 (38%) and 132 (62%) in SOC and early corticosteroid groups, respectively. The composite endpoint occurred at a significantly lower rate in the early corticosteroid group (34.9% vs 54.3%, P = .005). This treatment effect was observed within each individual component of the composite endpoint. Significant reduction in median hospital length of stay was also observed in the early corticosteroid group (5 vs 8 days, P < .001). Multivariate regression analysis demonstrated an independent reduction in the composite endpoint at 14-days controlling for other factors (adjusted odds ratio: 0.41; 95% confidence interval, .22 - .77). CONCLUSIONS: An early short course of methylprednisolone in patients with moderate to severe COVID-19 reduced escalation of care and improved clinical outcomes. CLINICAL TRIALS REGISTRATION: NCT04374071.
315 citations
Cites background from "A Framework for Rationing Ventilato..."
...The reduction in ICU transfer and requirement for mechanical ventilation represents a potential intervention to reduce critical care utilization during the COVID-19 pandemic [22, 23]....
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TL;DR: This work provides a toolbox of strategies for supporting family-centered inpatient care during physical distancing responsive to the current clinical climate and Innovations in the implementation of family involvement during hospitalizations may lead to long-term progress in the delivery of family- centered care.
247 citations
Cites background from "A Framework for Rationing Ventilato..."
...These processes should also aim to decrease the bedside clinical team’s moral distress and ‘‘avoid conflicts of commitments,’’ aligned with the recommended practices for resource allocation decisions.(12) The United States is permitting the use of technologies that may not be fully compliant with the Health Insurance Portability and Accountability Act Privacy, Security, and Breach Notification Rules (HIPAA Rules) during the COVID-19 public health emergency....
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TL;DR: The analysis suggests that the notion of a 'fair innings' notion of intergenerational equity requires greater discrimination against the elderly than would be dictated simply by efficiency objectives.
Abstract: Many different equity principles may need to be traded off against efficiency when prioritizing health care. This paper explores one of them: the concept of a 'fair innings'. It reflects the feeling that everyone is entitled to some 'normal' span of health (usually expressed in life years, e.g. 'three score years and ten') and anyone failing to achieve this has been cheated, whilst anyone getting more than this is 'living on borrowed time'. Four important characteristics of the 'fair innings' notion are worth noting: firstly, it is outcome based, not process-based or resource-based; secondly, it is about a person's whole life-time experience, not about their state at any particular point in time; thirdly, it reflects an aversion to inequality; and fourthly, it is quantifiable. Even in common parlance it is usually expressed in numerical terms: death at 25 is viewed very differently from death at 85. But age at death should be no more than a first approximation, because the quality of a person's life is important as well as its length. The analysis suggests that this notion of intergenerational equity requires greater discrimination against the elderly than would be dictated simply by efficiency objectives.
700 citations
TL;DR: The deliberations of the Subcommittee in identifying priorities for a new lung allocation system, the analyses undertaken by the OPTN and the Scientific Registry for Transplant Recipients and the evolution of a new Lung Allocation Score, incorporating waiting list and posttransplant survival probabilities are reviewed.
609 citations
TL;DR: The ethical principles that could guide allocation, an allocation strategy that balances multiple morally relevant considerations, and recommendations for meaningful public engagement in priority setting are analyzed.
Abstract: A public health emergency, such as an influenza pandemic, will lead to shortages of mechanical ventilators, critical care beds, and other potentially life-saving treatments. Difficult decisions about who will and will not receive these scarce resources will have to be made. Existing recommendations reflect a narrow utilitarian perspective, in which allocation decisions are based primarily on patients' chances of survival to hospital discharge. Certain patient groups, such as the elderly and those with functional impairment, are denied access to potentially life-saving treatments on the basis of additional allocation criteria. We analyze the ethical principles that could guide allocation and propose an allocation strategy that incorporates and balances multiple morally relevant considerations, including saving the most lives, maximizing the number of "life-years" saved, and prioritizing patients who have had the least chance to live through life's stages. We also argue that these principles are relevant to all patients and therefore should be applied to all patients, rather than selectively to the elderly, those with functional impairment, and those with certain chronic conditions. We discuss strategies to engage the public in setting the priorities that will guide allocation of scarce life-sustaining treatments during a public health emergency.
273 citations
TL;DR: The suggestions in this chapter are important for all who are involved in large-scale pandemics or disasters with multiple critically ill or injured patients, including front-line clinicians, hospital administrators, and public health or government officials.
174 citations
TL;DR: This Commentary focuses on traditional public health interventions, drawing lessons from past influenza pandemics and the outbreaks of severe acute respiratory syndrome (SARS).
Abstract: HIGHLY PATHOGENIC INFLUENZA A(H5N1) IS ENdemic in avian populations in Southeast Asia, with serious outbreaks now in Africa, Europe, and the Middle East. Human cases, although rare, continue to increase, with high reported case-fatality rates. Industrialized countries place great emphasis on scientific solutions. The White House strategic plan and congressional appropriation both devote more than 90% of pandemic influenza spending to vaccines and antiviral medications. Yet, medical countermeasures, discussed in a previous JAMA Commentary, will not impede pandemic spread: experimental H5N1 vaccines may not be effective against a novel human subtype, neuraminidase inhibitors may become resistant, and medical countermeasures will be extremely scarce. This Commentary focuses on traditional public health interventions, drawing lessons from past influenza pandemics and the outbreaks of severe acute respiratory syndrome (SARS) (TABLE). Public health strategies are difficult to evaluate. First, evidence of effectiveness is often historical or anecdotal, with few randomized trials or systematic studies. Adequate resources for population-based research are urgently needed. Second, an intervention’s effectiveness depends on the transmission pattern, which cannot be fully understood in advance. Key issues include viral shedding (infectivity during presymptomatic and postsymptomatic stages); mode and efficiency of transmission (large droplet, aerosol, contaminated hands and surfaces); incubation period; and serial interval between cases. Third, the usefulness of an intervention depends on the pandemic phase. In the pandemic alert period, surveillance, medical prophylaxis, and isolation are important tools. Yet, during a pandemic, the focus shifts to delaying spread through population-based measures. Thus, the key question is which measure, or combination of measures, works best at each stage of the pandemic? Multiple, targeted approaches are likely to be most effective but can have deep adverse consequences for the economy and civil liberties. The Public Health System: Surveillance Surveillance is the backbone of public health, providing essential data to understand the epidemic and inform the public. Surveillance strategies include rapid diagnosis, screening, reporting, case contact investigations, and monitoring trends. Currently, influenza A(H5N1) is not reportable in the United States, which requires reform of state law. The US public health infrastructure is deficient in laboratories, workforce, and data systems. Congress recently appropriated only $350 million to upgrade state and local capacity— approximately 9% of a total of $3.8 billion for pandemic influenza. Furthermore, this limited funding will be significantly eroded by a $105 million cut in federal support for state public health and an unfunded mandate for states to purchase antiviral drugs. The new international health regulations (IHR) require countries to develop core public health capacities to detect, assess, and notify the World Health Organization (WHO) of health emergencies with international significance. The mandate, however, is vacant without adequate resources for poor countries, which lack the capacity for human or animal surveillance and containment of outbreaks. Recently, donor countries pledged $1.9 billion to meet the costs estimated by the World Bank to contain avian influenza. Surveillance poses privacy risks as government collects sensitive health information from patients, travelers, and other vulnerable populations. The IHR require states to keep data “confidential and processed anonymously as required by national law.” The United States and the European Union have data protection statutes, but both make exceptions for surveillance. The United States and other countries should enact public health information privacy laws to prohibit wrongful disclosures—for example, to employers, insurers, and immigration or criminal justice authorities.
114 citations