TX-57

SHORE HEALTH SYSTEM

ADMINISTRATIVE POLICY AND PROCEDURE

TITLE OF POLICY: CRITICAL CARE AND VENTILATOR TRIAGE

GUIDELINES DURING A DISASTER EVENT

SCOPE:

To equitably allocate limited resources and maximize their benefit to patients requiring critical
care and ventilatory support during a public health emergency and to preserve public trust in
healthcare institutions.

This guideline will be activated in coordination with local resources and the local public health
agency.

PURPOSE:

To provide objective criteria for the allocation of critical care and ventilator resources during a
disaster event that exceeds the critical care and ventilator capacity of the institution.

DEFINITIONS:

1. Bag-Valve Mask (BVM) - Manual ventilation device.

2. Exclusion Criteria - Identify those patients who have a poor prognosis despite care in
the ICU, patients who require resources that simply cannot be provided during a
disaster, and patients with advanced medical illnesses whose underlying illness has a
poor prognosis with a high likelihood of death, and would not be appropriate for critical
care admission. (See Attachment 1)

3. Inclusion Criteria - Identify those patients who may benefit from admission to critical
care and primarily focus on respiratory failure. (See Attachment 1)

4. Mechanical Ventilator - Machine designed to deliver sophisticated ventilatory support

for patients in respiratory failure.

5. Prioritization Tool - Used in the triage protocol for the assessment of patients’ needs
for critical care during a disaster event initially, at 48 hours and at 120 hours. (See
Attachment 3)

6. SOFA Score – Scoring system to determine the extent of a person’s organ function or
rate of failure. The score is based on six different scores, one each for the respiratory,
cardiovascular, hepatic, coagulation, renal and neurological systems. (See Attachment
2)

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7. Triage – Focus is on the identifying and reserving immediate treatment for individuals
who have a critical need for treatment and are likely to survive.

8. Vortran Automatic Resuscitator (VAR) – Pressure-cycled, continuous flow disposable

ventilator able to deliver small tidal volumes at higher rates; designed to provide interim
ventilatory support.

1.0 POLICY

1.1 The decision for implementation of this guideline will be made by the Medical
Staff Director in the Incident Command Center in collaboration with caregivers
and the Ethics Committee.

1.2 Once the decision has been made, if the patient meets criteria for critical care,
the following procedure will be used as a guideline for restriction of ventilatory
support of this patient population during a disaster.

2.0 PROCEDURE

2.1 Tier 1 – Do not offer AND withdraw ventilatory support for patients with any one
of the following:

2.1.1 Respiratory failure requiring intubation with persistent hypotension

(systolic blood pressure < 90 mm Hg for adults), unresponsive to
adequate fluid resuscitation after 6-12 hours of therapy and signs of
additional end-organ function (e.g., oliguria, mental status changes,
cardiac ischemia).

2.1.2 Failure to respond to mechanical ventilation (no improvement in

oxygenation or lung compliance) and antibiotics after 72 hours of
treatment for a bacterial pathogen (timeline may be modified based on
organism-specific data).

2.1.3 Laboratory or clinical evidence of > 4 organ systems failing.

2.1.3.1 Pulmonary (ARDS, ventilatory failure, refractory hypoxemia).

2.1.3.2 Cardiovascular (left ventricular dysfunction, hypotension, new

ischemia).

2.1.3.3 Renal (hyperkalcemia, diminished urine output despite fluid

resuscitation, increasing creatinine level).

2.1.3.4 Hepatic (transaminase greater than 2 times normal upper limit,

increasing bilirubin or ammonia levels).

2.1.3.5 Neurologic (altered mental status not related to volume status,

metabolic or hypoxic source, stroke).

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2.1.3.6 Hematologic (clinical or laboratory evidence of disseminated

intravascular coagulation).

2.2 Tier 2 – Do not offer AND withdraw ventilatory support from patients with
respiratory failure requiring intubation with the following conditions (in addition to
those in Tier 1). Patients with pre-existing system compromise or failure
including:

2.2.1 Known congestive heart failure with ejection fraction <25% (or persistent
ischemia unresponsive to therapy and pulmonary edema).

2.2.2 Acute renal failure requiring hemodialysis (related to illness).

2.2.3 Severe chronic lung disease including pulmonary fibrosis, cystic fibrosis,
obstructive or restrictive diseases requiring continuous home oxygen use
before onset of acute illness.

2.2.4 Acquired immunodeficiency syndrome (AIDS), other immunodeficiency

syndromes at stage of disease susceptible to opportunistic pathogens
(e.g., CD4<200 for AIDS) with respiratory failure requiring intubation.

2.2.5 Active malignancy with poor potential for survival (e.g., metastatic
malignancy, pancreatic cancer).

2.2.6 Cirrhosis with ascites, history of variceal bleeding, fixed coagulopathy

or encephalopathy.

2.2.7 Acute hepatic failure with hyperammonemia.

2.2.8 Irreversible neurologic impairment that makes the patient dependent for
personal cares (e.g., severe stroke, congenital syndrome, persistent
vegetative state).

2.3 Tier 3 – Specific protocols to be agreed upon with input of ethics committee:
(may include):

2.3.1 Restriction of treatment based on disease-specific epidemiology and

survival data for patient subgroups (may include age-based criteria).

2.3.2 Expansion of pre-existing disease classes that will not be offered

ventilatory support.

2.3.3 Applying of SOFA scoring to the triage process and establishing a cutoff
score above which mechanical ventilation will not be offered.

2.4 Once the patient no longer meets inclusion criteria for critical care and ventilatory
support, the patient will be transitioned to palliative care or the appropriate level
of care indicated.

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Effective 08/08
Approved Medical Executive Committee: 08/06/08
Submitted Brian H. Childs, Ph.D., Director
Ethics

REFERENCES:

Christian, M.D., Hawryluck, L., Wax, R.S., Cook, T., Lazar, N.M., Herridge, M.S., Muller, M.P.,
Gowans, D.R., Fortier, W., Burkle, Jr., F.M. (2006). Development of a triage protocol for critical
care during an influenza pandemic. Canadian Medical Association Journal 2006, 175(11, 1377-
81.

Hick, J.L., & O’Laughlin, D.T. (2006). Concept of operations for triage of mechanical ventilation
in an epidemic. Academic Emergency Medicine 2006, 13:223-229.

Rando, F.G. (2006). Automatic resuscitators can serve as effective “force multipliers” for
emergency ventilatory support in mass casualty scenarios. Vortran Technical Report VAR-
0603.

University of Toronto Joint Centre for Bioethics, (2005, November). Stand on guard for thee;
Ethical considerations in preparedness planning for pandemic influenza. Toronto, Ontario:
Pandemic Influenza Working Group.

Critical Care and Ventilator Triage Guidelines

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