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J Crit Care ; 66: 33-43, 2021 12.
Article in English | MEDLINE | ID: covidwho-1370571


PURPOSE: This scoping review sought to identify objective factors to assist clinicians and policy-makers in making consistent, objective and ethically sound decisions about resource allocation when healthcare rationing is inevitable. MATERIALS AND METHODS: Review of guidelines and tools used in ICUs, hospital wards and emergency departments on how to best allocate intensive care beds and ventilators either during routine care or developed during previous epidemics, and association with patient outcomes during and after hospitalisation. RESULTS: Eighty publications from 20 countries reporting accuracy or validity of prognostic tools/algorithms, or significant correlation between prognostic variables and clinical outcomes met our eligibility criteria: twelve pandemic guidelines/triage protocols/consensus statements, twenty-two pandemic algorithms, and 46 prognostic tools/variables from non-crisis situations. Prognostic indicators presented here can be combined to create locally-relevant triage algorithms for clinicians and policy makers deciding about allocation of ICU beds and ventilators during a pandemic. No consensus was found on the ethical issues to incorporate in the decision to admit or triage out of intensive care. CONCLUSIONS: This review provides a unique reference intended as a discussion starter for clinicians and policy makers to consider formalising an objective a locally-relevant triage consensus document that enhances confidence in decision-making during healthcare rationing of critical care and ventilator resources.

COVID-19 , Pandemics , Critical Care , Health Care Rationing , Humans , Triage , Ventilators, Mechanical
N Z Med J ; 133(1527): 95-103, 2020 12 18.
Article in English | MEDLINE | ID: covidwho-979363


AIM: To evaluate rates of unplanned ICU admissions before, during and after New Zealand's COVID-19 Alert Level 4/3 lockdown, and to describe the characteristics and outcomes of patients admitted to Wellington ICU during lockdown in comparison to historical controls. METHOD: We conducted a retrospective cohort study using the Wellington Hospital ICU database and included patients with an unplanned ICU admission during the first 35 weeks of the year from 2015 to 2020 inclusive. The primary variable of interest was the rate of unplanned ICU admission in 2020 compared with historical controls. We also described the characteristics and outcomes of patients with unplanned admissions to ICU during the 2020 COVID-19 lockdown compared to historical controls. RESULTS: During the five weeks of Alert Level Four, and the subsequent two weeks of Alert Level Three, the number of unplanned ICU admissions per day fell to 1.65±1.52 compared to a historical average of 2.56±1.52 ICU unplanned ICU admissions per day (P<0.0001). The observed reduction in ICU admission rates appeared to occur for most categories of ICU admission diagnosis but was not evident for patients with neurologic disorders. The characteristics and outcomes of patients who had unplanned admissions to Wellington ICU during the COVID-19 lockdown were broadly similar to historical controls. The rate of unplanned ICU admissions in 2020 before and after the lockdown period were similar to historical controls. CONCLUSION: In this study, we observed a reduction in unplanned admissions to Wellington Hospital ICU associated with New Zealand's initial COVID-19 lockdown.

COVID-19/epidemiology , Communicable Disease Control/methods , Intensive Care Units/statistics & numerical data , Patient Admission/trends , Quarantine , SARS-CoV-2 , Female , Follow-Up Studies , Hospital Mortality/trends , Humans , Male , Middle Aged , New Zealand/epidemiology , Retrospective Studies
Breathe (Sheff) ; 16(2): 200062, 2020 Jun.
Article in English | MEDLINE | ID: covidwho-886500


The patient and family perspective on the appropriateness of intensive care unit (ICU) treatments involves preferences, values and social constructs beyond medical criteria. The clinician's perception of inappropriateness is more reliant on clinical judgment. Earlier consultation with families before ICU admission and patient education on the outcomes of life-sustaining therapies may help reconcile these provider-patient disagreements. However, global emergencies like COVID-19 change the usual paradigm of end-of-life care, as it is a new disease with only scarce predictive information about it. Pandemics can also bring about the burdensome predicament of doctors having to make unwanted choices of rationing access to the ICU when demand for otherwise life-saving resources exceeds supply. Evidence-based prognostic checklists may guide treatment triage but the principles of shared decision-making are unchanged. Yet, they need to be altered with respect to COVID-19, defining likely outcomes and likelihood of benefit for the patient, and clarifying their willingness to take on the risks inherent to being in an ICU for 2 weeks for those eligible. For patients who are admitted during the prodrome of COVID-19 disease, or those who deteriorate in the second week, clinicians have some lead time in hospital to have appropriate discussions about ceilings of treatments offered based on severity. KEY POINTS: The patient and family perspective on inappropriateness of intensive care at the end of life often differs from the clinician's opinion due to the nonmedical frame of mind.To improve satisfaction with communication on treatment goals, consultation on patient values and inclusion of social constructs in addition to clinical prediction is a good start to reconcile differences between physician and health service users' viewpoints.During pandemics, where health systems may collapse, different admission criteria driven by the need to ration services may be warranted. EDUCATIONAL AIMS: To explore the extent to which older patients and their families are involved in decisions about appropriateness of intensive care admission or treatmentsTo understand how patients or their families define inappropriate intensive care admission or treatmentsTo reflect on the implications of decision to admit or not to admit to the intensive care unit in the face of acute resource shortages during a pandemic.