IMPORTANCE OF PATIENT THROUGHPUT WHEN SIMULATING CRISIS STANDARDS OF CARE: EXCLUSION CRITERIA AND TRIAGE SCORE MODIFIERS

ABSTRACT

SESSION TITLE What Lessons Will We Take From the Pandemic? SESSION TYPE Rapid Fire Original Inv PRESENTED ON 10/19/2022 1115 am - 1215 pm PURPOSE: COVID-19 surges due to variants continue to intermittently strain healthcare resources, highlighting the need to refine crisis standards of care (CSC) guidelines and study how they may perform in actuality. Studies to date, focusing on excess deaths or exacerbations of existing health disparities, simulate retrospective patient cohorts that synchronize patient presentation to a single point in time, rather than the reality where patients present continually throughout time. This artificial static model may not be an accurate reflection of patient throughput and dynamic resource strain, which occurs in reality, and might distort patient cohorts and mislead CSC simulated outcomes. METHODS: All intubated COVID-19 patients in a single healthcare system in New York City during the first surge (1/1/20 to 6/30/20) were included. A crisis period requiring CSC activation was defined as occurring once 95% of pre-pandemic ventilators were utilized and lasted 2 weeks in duration, consistent with prior simulated length of CSC for this cohort under the New York State Ventilator Allocation Guidelines (NY). NY, Maryland (MD), Pittsburgh (PA), Saskatchewan Canada (SAC), and California (CA) CSC policies were reviewed for exclusionary and other criteria that would affect patient triage (admission diagnosis, comorbidities, occupation, or other patient circumstances). NY, MD, SAC, and CA all use exclusionary criteria. Subsequently NY and SAC only use a SOFA score for triage whereas MD, PA, and CA all integrate tiered comorbidities in addition to a SOFA score to generate an overall triage score. Partial triage priority is provided by PA, SAC, and CA for certain occupations and by PA for those socially disadvantaged. Patient charts were reviewed to determine if they would satisfy triage criteria from any of these guidelines and if they would be relevant during the specific crisis period. RESULTS: 936 patients were included in the total cohort, of which 573 were involved during the crisis period. Those not involved during the crisis period required a ventilator when less than 95% of all ventilators were utilized and would not be relevant during a CSC simulation. NY, MD, PA, SAC, and CA would have excluded 1, 3, 0, 79, and 4 patients respectively for the entire cohort, but 0, 0, 0, 29 (36.7%), and 2 (50%) during the specific crisis period. MD, PA, & CA would have modified 49, 88, & 102 individual’s triage score due to comorbidities in the entire cohort but only 17 (34.7%), 40 (45.5%), and 41 (40.2%) during the crisis period respectively. CONCLUSIONS: CSC simulations that include patients outside the crisis period will include patients that may not be relevant to understanding how CSC might perform. CLINICAL IMPLICATIONS Understanding CSC performance, particularly when studying excess deaths or exacerbating social disparities, requires incorporating patient throughput for an accurate real-world understanding. DISCLOSURES No relevant relationships by Deepak Pradhan No relevant relationships by Brandon Walsh