Research focuses on triage during pandemic

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BY Suzanne Morrison

November 21, 2006

[img_inline align=”right” src=”http://padnws01.mcmaster.ca/images/Christian.gif” caption=”Dr. Michael Christian, an infectious disease specialist at McMaster University, led a group of researchers in the development of a triage plan to be used as a guide during an influenza pandemic. File photo.”]Should an influenza pandemic hit, hospitals and intensive care units could be flooded with patients requiring critical care, but not enough ventilators and antiviral medications to go around.

In preparation for such a catastrophe, McMaster University infectious disease specialist Dr. Michael Christian led a group of researchers in the development of a triage plan to be used as a guide during the initial days and weeks of an influenza pandemic.

The triage protocol, which defines who should receive care and what level of care, appears in the Nov. 21 issue of the Canadian Medical Association Journal (CMAJ).

The researchers say that although all patients should have an equal claim to receive the health care they need, that likely won't happen during a pandemic.

“Unfortunately, during a pandemic it will not be possible for all patients to receive intensive care due to finite resources,” they said in the paper. “A triage protocol will assist in distributing the available resources fairly by triaging patients who will not benefit from treatment to non-critical care management, thereby conserving critical care resources for patients who are more likely to benefit.”

The protocol outlines the criteria for identifying patients who have a good chance of benefiting from ventilator support, as well as those who would need similar resources, but whose prognosis is poor. Since there won't be enough resources for all, the protocol aims to determine which patients should receive intensive care, based on the likelihood of survival.

In developing the protocol, the researchers drew on features of protocols established for other crises, such as trauma and nuclear events. One of these was a colour-coded decision tool, based on the Sequential Organ Failure Assessment (SOFA) score, where higher ratings are associated with increased morbidity and mortality. Using the tool, the protocol suggests:

  • Patients with no significant organ failure  in the “green” zone  would be deferred or discharged and re-evaluated as needed.
  • Patients with a SOFA score between eight and 11 (yellow) would get intermediate priority.
  • Patients with a SOFA score less than or equal to seven (red) would get the highest priority.
  • Patients who either meet one of the exclusion criteria or have a SOFA score greater than 11 (blue) would be managed medically or given palliative care, and discharged from care.

    The triage protocol also places a ceiling on the amount of resources expended on any one person.

    In an accompanying commentary to the CMAJ paper, Dr. Ryan M. Melnychuk, a postdoctoral fellow in ethics and health research and policy at Dalhousie University, and Nuala Kenny, a professor in the department of bioethics, note that this protocol has never been used and was developed by a panel of experts without public input.

    They say that although the research team led by Christian addressed one of many difficult decisions that will confront pandemic planners across Canada, they failed to indicate the values on which their triage protocol is based.

    “There is an urgent need for a national ethical framework that makes explicit the values and principles that will guide pandemic influenza planning,” they said.