Christ Hospital
Courtesy Dr. Tucker Woods

Guidelines call for triage teams to save lives and life-years; Murphy and Persichilli insist no patient would be excluded based on age, race, sex, gender identity and other concerns

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By Lilo H. Stainton

While there are some signs the impact of the coronavirus may be lessening in New Jersey, state officials have distributed guidelines to help hospitals allocate patient resources if there are widespread shortages of things like ventilators or other critical-care supplies.

State Department of Health commissioner Judith Persichilli said the “triage guidelines” issued Saturday evening would not be activated unless a hospital’s intensive-care capacity was overwhelmed and assistance or supplies could not be provided by another facility in the region.

The document outlines a decision-making framework that a triage team can use to assign a score to patients in need of critical care — whether they have COVID-19 or another condition — based in part on the likelihood of short- and long-term survival. These scores would be used to determine who is allocated resources if there are not enough to go around.

Or as Persichilli said Monday, “in case demand for public health resources outstrips supply.” She further explained,  “The framework is designed to create meaningful access for all patients who are eligible for critical-care or intensive-care services during ordinary circumstances remain eligible.”

Saving lives and life-years

The framework is based largely on two considerations: saving lives and saving life-years, which would likely benefit younger, healthier patients. Providers can also chose to prioritize those in health care roles, the guidelines note. “The goal of the allocation framework is to achieve benefit for populations of patients, often expressed as doing the greatest good for the greatest number,” Persichilli said.

No patient would be deemed ineligible for consideration based on age, race, sex, gender identity or sexual preference, physical or mental ability, role in society or insurance status, among other things, Persichilli and Gov. Phil Murphy stressed.

“It ensures that no one is denied care based on stereotypes, assessments of quality of life, or judgment about a person’s worth based on the presence or absence of disability or other factors,” Persichilli said. The guidelines are “intended to be the last resort (and) we hope they won’t be needed,” she added.

COVID-19 has now been detected in nearly 64,600 New Jerseyans, including more than 2,400 who have died — more than the state lost in battle during the Korean and Vietnam wars, Murphy said Monday.

Hospital and testing data collected by the state suggests that the daily number of hospital admissions is starting to decline and the pace of new positive diagnoses may be slowing. But the governor underscored the need to continue strict social distancing to allow these positive trends to continue.

“We’re not out of the woods yet,” Murphy said Monday, shortly after a joint press event with a handful of other governors from the region to indicate they will coordinate recovery plans. According to one well-respected predictive model, the overall death toll from coronavirus could continue to rise for weeks and eventually reach nearly 5,300.

Still struggling with shortages

Good signs aside, state officials have faced what appears to be a daily struggle to obtain enough supplies — particularly face masks and ventilators — and staffing to help hospitals properly care for the patients they have.  The state was down to 61 ventilators on Sunday but received 200 more from a federal stockpile Monday morning; it has also drafted volunteers, contracted with staffing agencies and called on combat medics to supplement the workforce at nursing homes and medical field facilities.

Murphy has repeatedly underscored the need to “plan for the worst” in the state’s response, a process that includes ordering multiple refrigerated trailers in case hospitals run out of space in their morgues for the dead. In late March, he outlined the need for New Jersey to create a system for allocating health care resources, noting he would be “abrogating our responsibilities not to prepare for that awful potentiality.”

As a result, a committee empaneled by the Medical Society of New Jersey began to review examples of various ethical guidelines and submitted a draft proposal to the DOH in late March. Ethics experts said these models are designed to save the most lives possible with the resources available and require physicians to make a dramatic shift from focusing on a single patient — as they are trained — to considering the needs of the community at large.

On Monday Persichilli said New Jersey adapted a model developed by the University of Pittsburgh’s Department of Critical Care Medicine; the 13-page document on the DOH website appears nearly identical, with the same graphics and font, to the version posted by Pittsburgh. “This allocation framework is grounded in ethical obligations that include the duty to care, duty to steward resources to optimize population health, distributive and procedural justice, and transparency,” the introduction states.

The guidance — which can’t take effect unless the government has declared a public health emergency, as Murphy did last month — only applies if the hospital is operating in a crisis standard, or under guidelines designed to promote safety and preserve resources, and has or will soon run out of space, staff or other resources in its intensive-care unit, according to the summary section.

The framework is designed to guide providers in deciding which new patients get scarce resources, but also involves “reassessment criteria” to help them decide if someone currently on a ventilator, for example, should continue to have access to the lifesaving device. If the need involves breathing assistance, providers must first seek to use converted anesthesia machines, CPAP masks for sleep apnea or other devices proven to “support pulmonary function” before rationing the ventilators, Persichilli said.

Assembling triage teams

Specifically, the guidance calls for hospitals to create triage teams that will step in and make these assessments, sparing the attending doctor and nurses from having to decide who gets what resources. These teams would work in shifts lasting no longer than 13 hours, according to the plan, and would also be responsible for informing families of the decisions made and considering appeals in some circumstances.

Teams would assess patients who are in need of critical care — and able to withstand the treatment required, some of which may be highly invasive — and assign each a score, based on the potential for organ failure and short-term survivability. The team would also consider how long the patient would likely live after being discharged from the hospital. Points are assigned for these categories and those with the lowest score would be given treatment priority.

The guidelines also list “other scoring considerations” like prioritizing those who are part of the coronavirus response, including key health care workers — but notes all staff, from physicians to floor cleaners, should be considered on par. The document also suggests “life-cycle considerations” be used as a tiebreaker, if needed, with preference for younger people who have yet to experience multiple life stages. A lottery system can also be used, if a tie remains.

The framework notes it does not involve categorical exclusionary criteria that deem certain groups or patients ineligible for consideration or “not worth saving,” as the document reads.  But eligibility does not mean they will get care, if resources are limited.

“Patients who are not triaged to receive critical care/ventilation will receive medical care that includes intensive symptom management and psychosocial support. They should be reassessed daily to determine if changes in resource availability or their clinical status warrant provision of critical-care services,” the plan notes.

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