How useful are sequential organ failure assessment (sofa) score-based ventilator triage guidelines during the COVID-19 pandemic?

ABSTRACT

RATIONALE COVID-19 activity continues to cause a high disease burden, and hospitals are vulnerable to ventilator scarcity. Crisis standards of care aim to maximize lives saved and to minimize clinician distress from bedside rationing. 26 states have allocation guidelines. 15 use the Sequential Organ Failure Assessment (SOFA) score. SOFA predicts mortality in hospitalized patients and provides objective data to reduce the risk of introducing bias. We use data from the COVID-19 surge in New York City (NYC) to model performance of a protocol based on SOFA scores and NY State guidelines. Although these guidelines were not implemented, we estimate the hypothetical outcomes had they been required. METHODS: This is a chart review of a random sample (205) of all intubated patients (1002) in three NYC hospitals between 25 March 2020 and 29 April 2020. Patients with and without COVID-19 were included. SOFA scores were calculated upon intubation, 48-, and 120-hours post-intubation. We calculated mortality and proportion of patients categorized into four groups blue (ventilator not offered or removed), red (highest priority), yellow (intermediate priority), and green (weaned or ventilation not indicated) at each interval. RESULTS: 65 (32%) patients survived to discharge (Figure). 117 patients (57%) were categorized blue at least once;28 (24%) of those ultimately survived hospitalization. Patients ever in blue category had higher mortality (76%) compared with those never categorized blue (58%;p<0.01). Of expired patients, 89 (63%) were ever categorized as blue. CONCLUSIONS: Since over half of all patients met exclusion criteria at one or more time points, clinical judgment may still be needed to decide which patients would be excluded first. This re-introduces bias and moral distress;issues effective triage protocols should address. More specific scoring systems, such as 4C mortality score, may improve performance. Alternative strategies including first-come, first-served, randomization, clinician judgement, and triage committees lack empirical data and have ethical shortcomings. Our findings differ from a recent retrospective cohort study, which found few patients outside of the pandemic met New York State guideline blue category criteria among more than 40,000 ICU admissions. Our sample more closely reflects the acuity of pandemic conditions when this allocation guideline would be activated. The data from this preliminary study suggest that the SOFA score offers limited utility in triage, raising the question of whether sufficient ethical justification exists to impose a life-ending decision on a subset of patients to offer potential benefit to a modest number of others.