Methodist Hospital Policy MA309 - Triage Policy - Allocation of Scarce Critical Care Resources During a Public Health Emergency

PURPOSE:

To outline the approach of Methodist Hospital of Southern California (MHSC) for the triage of critically ill patients when a public health emergency creates demand for critical care resources (e.g., acute care rooms, medical equipment such as ventilators and personal protective equipment, medicines and/or staff) that outstrips available supply.

POLICY:

MHSC will establish a Hospital Triage Team (HTT) that shall set forth guidance and process for determining emergency allocation of acute care resources in the event of an officially designated disaster or pandemic, or when the critical needs of patients exceed the current ability to provide such resources and all usual reasonable and appropriate measures have been exhausted.

PROCEDURE:

  • Structure and Function
    • The HTT reports to the Medical Executive Committee (MEC). The HTT will be implemented no later than the start of surge conditions and is led by the Hospital Triage Officer (HTO), which is either the Chief of Staff or his/her designee. This individual will oversee the processes of (i) forming and educating triage team members during surge conditions, and (ii) making allocation decisions during crisis, which includes assessing all patients, assigning a level of priority for each, communicating with treating physicians, and directing attention to the highest-priority patients.
    • The HTT members consist of the HTO, or designee, Chair of the Bioethics Committee or designee, and a minimum of two physicians and a community member or designee.
  • Executive Support
    • MHSC’s senior leadership and MEC senior leadership is responsible for appointing members to the triage team no later than during surge conditions. A roster of approved triage committee members should be maintained that is large enough to ensure that they will always be available on short notice.
    • The rationale for all allocation decisions is comprehensively documented in the medical chart/EHR and in ways that facilitate rapid, real-time reporting as described herein.
  • Ethical Framework
    • Duty to Care
      • ​Healthcare professionals have a duty to care, even at personal risk. This includes a commitment to delivering the best care possible given the available resources. In a crisis, every patient should receive compassionate care, whether aimed at maximizing survival or supporting a dignified death.
    • Duty to Steward Resources
      • In crisis, all resources are potentially scarce, and all clinicians have a duty to protect them. All resources should be carefully allocated according to their known scarcity, the likelihood of renewal, and the extent to which they can be replaced or reused.
    • Distributive and Procedural Justice
      • A system of allocation during crisis must be applied consistently and broadly, to maximize fairness and minimize the influence of bias. These standards will be applied equitably across populations without regard to patient race, gender, creed, color, sexual orientation, gender identity or expression, disability, ethnicity, religion, or socioeconomic status. Allocation decisions should seek to support access to care for all, regardless of their insurance status, and in consideration for the most vulnerable or those who suffer disproportionately.
    • Reciprocity
      • Health care professionals, by virtue of the healing relationships they support through their work, may be justly given preference for scarce critical care resources under some circumstances
    • Transparency
      • To the extent practically feasible, allocation plans should be communicated as efficiently, widely, and comprehensively as possible across the MHSC and moral community, inclusive of government agencies, nearby healthcare facilities, staff, patients, and other stakeholders. Such transparency is likely to minimize actual and vicarious trauma to patients, loved ones, staff, and members of the public.
  • Usage of Existing Ethics Policies
    • Hospital policies already in effect will be helpful in supporting ethical medical decision-making under normal and surge conditions prior to the implementation of triage standards of care. These include:
      • Policy# MS1305: “Do Not Attempt Resuscitation (DNAR)/Allow Natural Death (AND) & Withholding and Withdrawing Life-Sustaining Treatment.” This policy supports an attending physician in making decisions about a patient’s code status in the event a patient’s surrogate is in disagreement with the physician’s recommendation. It will support a physician in changing a patient’s code status during normal operations conditions and surge conditions, prior to the implementation of crisis standards of care. This policy also supports an attending physician in responding to requests for treatment that are perceived as non-beneficial, which may support a physician in unilaterally redirecting care toward more comfort-oriented treatment.
      • Policy# MA1336: “Healthcare Decision-making for Unrepresented and Incapacitated Patients.” This policy supports a treating physician in making treatment decisions that would otherwise require documented informed consent and the patient both lacks capacity and an available decision-maker. In this case, decisions may be made by The Healthcare Decision-making Team (HDT). When the hospital experiences a surge of patients to such an extent that triage standards of care are activated, it is more likely than in normal circumstances that recognized healthcare decision-makers for patients who lack capacity will themselves be unable to participate in decision making
  • Triage Mechanism
    • During crisis conditions, the HTT will use an explicit allocation framework to determine priority scores of all patients eligible to receive scarce critical care resources.
    • For patients already being supported by a scarce resource, the evaluation will include reassessment to evaluate for clinical improvement or worsening at pre-specified intervals.
    • The HTO will review the comprehensive list of priority scores for all patients and will communicate with the attending physicians immediately after a decision is made by the triage team regarding the allocation or reallocation of a critical care resource.
  • Allocation Process for Scarce Critical Care Resources
    • During crisis conditions, a clinical assessment algorithm is coupled with a decision-making process to produce an allocation framework for making initial triage decisions for patients who present with illnesses that typically require critical care resources. (SEE APPENDIX A): Clinical Algorithm for Allocating Critical Care and Mechanical Ventilators in the Setting of a Crisis)
    • The framework must be applied to all patients presenting with critical illness, not simply those with the disease or disorders that arise from the public health emergency.
  • Communication of Allocation Decisions
    • The HTO should inform the affected patient’s attending physician about the allocation decision, then they should collaboratively determine the best approach to inform the individual patient and family.
  • Quality Assessment, Oversight, and Reporting
    • The CEO or his/her designee is responsible for rapidly developing and deploying a method of tracking the implementation of this policy, and longitudinally analyzing its performance.
    • Under such a scenario, the CEO or his/her designee is responsible for allocating a quality analyst or individual with equivalent capabilities, to be overseen by the Comprehensive Quality Improvement Systems (CQIS) Chair to process the data emerging from the triage team activities, so that it can be regularly reported to MHSC MEC and Board of Directors for the purposes of oversight.
  • Appeals Process for Allocation Decision
    • There is an appeals process in the event a patient/patient surrogate or healthcare provider challenges an individual allocation decision. An appeal may not be brought based on an objection to the overall allocation framework.
    • For the initial allocation decision, an appeal may be based on a claim that an error was made by the HTT in the calculation of the priority score. The process of evaluating the appeal should consist of the HTT verifying the accuracy of the priority score calculation by recalculating the score.
    • For an appeal to withdraw a scarce critical care resource from a patient who is already receiving it, the appeal process includes:
      • The appeal should be immediately brought to the HTT.
      • The individuals who are appealing the allocation decision should explain their disagreement with the decision.
      • The HTT should explain the grounds for the allocation decision that was made.
      • The appeals process must occur quickly enough that the appeals process does not harm patients who are in the queue for the scarce resource. If this is untenable, simple verification priority scoring should be offered.
      • The decision of the HTT will be final.
  • Educational Materials
    • As needed, the HTT will develop educational materials for leaders, frontline healthcare providers, staff, and other stakeholders explaining allocation decision-making in a crisis setting, including the ethical framework and clinical algorithms that support decision making.