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Validation of a Crisis Standards of Care Model for Prioritization of Limited Resources During the Coronavirus Disease 2019 Crisis in an Urban, Safety-Net, Academic Medical Center.
Nadjarian, Albert; LeClair, Jessica; Mahoney, Taylor F; Awtry, Eric H; Bhatia, Jasvinder S; Caruso, Lisa B; Clay, Alexis; Greer, David; Hingorani, Karan S; Horta, L F B; Ibrahim, Michel; Ieong, Michael H; James, Thea; Kulke, Matthew H; Lim, Remington; Lowe, Robert C; Moses, James M; Murphy, Jaime; Nozari, Ala; Patel, Anuj D; Silver, Brent; Theodore, Arthur C; Wang, Ryan Shufei; Weinstein, Ellen; Wilson, Stephen A; Cervantes-Arslanian, Anna M.
  • Nadjarian A; Department of Medicine, Section of General Internal Medicine, Boston Medical Center, Boston, MA.
  • LeClair J; Boston University School of Medicine, Boston, MA.
  • Mahoney TF; Boston Medical Center, Boston, MA.
  • Awtry EH; Department of Biostatistics, Boston University School of Public Health, Boston, MA.
  • Bhatia JS; Department of Biostatistics, Boston University School of Public Health, Boston, MA.
  • Caruso LB; Boston University School of Medicine, Boston, MA.
  • Clay A; Boston Medical Center, Boston, MA.
  • Greer D; Department of Medicine, Section of Cardiology, Boston Medical Center, Boston, MA.
  • Hingorani KS; Boston University School of Medicine, Boston, MA.
  • Horta LFB; Boston Medical Center, Boston, MA.
  • Ibrahim M; Department of Medicine, Section of Nephrology, Boston Medical Center, Boston, MA.
  • Ieong MH; Department of Medicine, Section of General Internal Medicine, Boston Medical Center, Boston, MA.
  • James T; Boston University School of Medicine, Boston, MA.
  • Kulke MH; Boston Medical Center, Boston, MA.
  • Lim R; Department of Biostatistics, Boston University School of Public Health, Boston, MA.
  • Lowe RC; Department of Medicine, Section of Cardiology, Boston Medical Center, Boston, MA.
  • Moses JM; Department of Medicine, Section of Nephrology, Boston Medical Center, Boston, MA.
  • Murphy J; Department of Neurology, Boston Medical Center, Boston, MA.
  • Nozari A; Department of Medicine, Section of Pulmonary, Allergy, and Critical Care Medicine, Boston Medical Center, Boston, MA.
  • Patel AD; Department of Emergency Medicine, Boston Medical Center, Boston, MA.
  • Silver B; Department of Medicine, Section of Hematology and Oncology, Boston Medical Center, Boston, MA.
  • Theodore AC; Department of Medicine, Section of Gastroenterology, Boston Medical Center, Boston, MA.
  • Wang RS; Department of Pediatrics, Boston Medical Center, Boston, MA.
  • Weinstein E; Department of Quality and Patient Safety, Boston Medical Center, Boston, MA.
  • Wilson SA; Department of Anesthesiology, Boston Medical Center, Boston, MA.
  • Cervantes-Arslanian AM; Office of the General Counsel, Boston Medical Center, Boston, MA.
Crit Care Med ; 49(10): 1739-1748, 2021 10 01.
Article in English | MEDLINE | ID: covidwho-1475872
ABSTRACT

OBJECTIVES:

The coronavirus disease 2019 pandemic has overwhelmed healthcare resources even in wealthy nations, necessitating rationing of limited resources without previously established crisis standards of care protocols. In Massachusetts, triage guidelines were designed based on acute illness and chronic life-limiting conditions. In this study, we sought to retrospectively validate this protocol to cohorts of critically ill patients from our hospital.

DESIGN:

We applied our hospital-adopted guidelines, which defined severe and major chronic conditions as those associated with a greater than 50% likelihood of 1- and 5-year mortality, respectively, to a critically ill patient population. We investigated mortality for the same intervals.

SETTING:

An urban safety-net hospital ICU. PATIENTS All adults hospitalized during April of 2015 and April 2019 identified through a clinical database search.

INTERVENTIONS:

None. MEASUREMENTS AND MAIN

RESULTS:

Of 365 admitted patients, 15.89% had one or more defined chronic life-limiting conditions. These patients had higher 1-year (46.55% vs 13.68%; p < 0.01) and 5-year (50.00% vs 17.22%; p < 0.01) mortality rates than those without underlying conditions. Irrespective of classification of disease severity, patients with metastatic cancer, congestive heart failure, end-stage renal disease, and neurodegenerative disease had greater than 50% 1-year mortality, whereas patients with chronic lung disease and cirrhosis had less than 50% 1-year mortality. Observed 1- and 5-year mortality for cirrhosis, heart failure, and metastatic cancer were more variable when subdivided into severe and major categories.

CONCLUSIONS:

Patients with major and severe chronic medical conditions overall had 46.55% and 50.00% mortality at 1 and 5 years, respectively. However, mortality varied between conditions. Our findings appear to support a crisis standards protocol which focuses on acute illness severity and only considers underlying conditions carrying a greater than 50% predicted likelihood of 1-year mortality. Modifications to the chronic lung disease, congestive heart failure, and cirrhosis criteria should be refined if they are to be included in future models.
Subject(s)

Full text: Available Collection: International databases Database: MEDLINE Main subject: Crisis Intervention / Resource Allocation / COVID-19 Type of study: Cohort study / Observational study / Prognostic study Limits: Adult / Female / Humans / Male / Middle aged Country/Region as subject: North America Language: English Journal: Crit Care Med Year: 2021 Document Type: Article Affiliation country: CCM.0000000000005155

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Full text: Available Collection: International databases Database: MEDLINE Main subject: Crisis Intervention / Resource Allocation / COVID-19 Type of study: Cohort study / Observational study / Prognostic study Limits: Adult / Female / Humans / Male / Middle aged Country/Region as subject: North America Language: English Journal: Crit Care Med Year: 2021 Document Type: Article Affiliation country: CCM.0000000000005155