Guidelines for the triage of critically ill patients if the COVID-19 public health emergency creates demand for critical care resources (ventilators, critical care beds) that outstrips the supply, have been issued by the Critical Care Society of SA.
The criteria to ration ventilators and critical care beds during the anticipated surge in COVID-19 cases, puts patients over the age of 75 at the bottom of the list of priorities. With guidelines issued by the Critical Care Society of Southern Africa in the event that the demand for ventilators will be greater than the available units, an ethicist reportedly told The Witness the measures are justifiable in a pandemic.
The document suggests several stages of assessment and scoring for all patients in need of ventilators – not only those with COVID-19 – taking into account each individual’s frailty and medical history. In the event of a “tie” between two patients, it suggests the younger person should be prioritised. It also proposes “heightened priority” to people “who perform tasks that are vital to the public health response – specifically, those whose work supports the provision of acute care to others”.
South Africa has about 7,000 critical care beds, of which 3,000 are not occupied at any one time, and about 6,000 ventilators. Medico-legal ethicist Professor Jerome Singh said “the rationing of intensive care beds and ventilators will be crucial to mitigating this scenario”.
The guidelines propose four age groups, in descending order of priority – 12 to 40, 41 to 60, 61 to 75 and 75-plus. The reason for this is based on the goal to give individuals equal opportunity to pass through all stages of life: childhood, young adulthood, middle age and old age.
Health workers given heightened priority “should be broadly construed to include those individuals who play a critical role in the chain of treating patients and maintaining societal order”. Singh said while it was not clear how clinicians would be able to decide who to put in this group amid a pandemic surge, such prioritisation is ethically defensible.
[link url="https://criticalcare.org.za/wp-content/uploads/2020/04/Allocation-of-Scarce-Critical-Care-Resources-During-the-COVID-19-Public-Health-Emergency-in-South-Africa.pdf"]Guidelines[/link]
[link url="https://criticalcare.org.za/wp-content/uploads/2020/04/CCSSA-SUMMARY-COVID-19-TRIAGE-ALGORITHM.pdf"]COVID-19 Triage Algorithm[/link]
[link url="http://thewitness.newspaperdirect.com/epaper/showarticle.aspx?article=589741fb-5bb2-4164-bed2-90d842810390&key=kiMNaAIbYDzqeSqE3BxMUw%3d%3d&issue=69122020050400000000001001"]Full report in The Witness (subscription needed)[/link]