Prospective evaluation of discerning power of 2 different ventilator triage criteria

ABSTRACT

INTRODUCTION/HYPOTHESIS: By identifying patients most likely to survive with ventilator support, health systems could improve survival rates among those afflicted and increase ventilator availability for subsequent patients during resource poor pandemic situations. The goal of this study was to prospectively evaluate the utility and discerning power of two different ventilator triage models (Whit & Lo and New York guidelines). METHODS: Prospective observational study of consecutive patients (N=1076) admitted to the Medical Intensive Care Unit during the COVID-19 pandemic from May to August 2020. New York State triage criteria and those proposed by White and Lo were applied. Characteristics and outcomes of those meeting initial criteria for the lowest level of priority for mechanical ventilation (using both criteria) were assessed. Agreement was compared between the 2 sets of triage criteria RESULTS: Among 1076 patients who received mechanical ventilation, the mean (SD) age was 60.5 (15.6) years, 618 (57.4%) were males, 659 (61.5%) were Caucasian, the mean BMI (SD) 30.4 (10.0), 135 (12.5%) had COVID and their SOFA score on admission day was 6.4 (3.0). Comparing the White and Lo triage criteria vs New York guidelines, 159 patients (14.7%) were in the lowest priority category vs 76 patients (7.06%);the mean (SD) age of 63.5 (15.2) years vs 56.2 (15.0) years, 88 (55.3%) vs 42 (55.3%) were males, 104 (65.4%) vs 52 (68.4%) were Caucasian, the mean BMI (SD) 28.8 (7.3) vs30.9 (8.5), 17 (10.7%) vs 4 (5.3%) had COVID, the mean (SD) SOFA score on admission day was 10.2 (2.9) vs 12.9 (1.4), 103 (64.8%) vs 63 (82.9%) patient received MV, the mean (SD) day on MV was 3.7 (5.6) vs 5.5 (6.8), 85 (53.5%) vs 37 (48.7%) survived. Only 63 admissions (5%) were in the lowest priority category for both guidelines, with the κ statistic for agreement equal to 0.40 (95% CI, 0.36-0.45). CONCLUSIONS: Five percent of admissions were identified as having the lowest priority for ventilator allocation using proposed guidelines with moderate agreement. Approximately a third of these patients (low probability) in both triage criteria survived to discharge. Valid and equitable allocation of limited critical resources should be based on sound scrutiny of proposed triage criteria.