Ethical Risk: Hospital Triage Decisions

I am grateful for the opportunities to organize and lead some fascinating discussion panels on ethical issues confronting hospital’s management of COVID challenges. This includes an October panel featuring Marcia Saxe-Braithwaite, Sacha Bhatia, and Toby Yan. Another triage decision-making session is to take place later in January.

The Issue

This blog focuses upon what ethics-related decision-making will need to take place during COVID wave two to ensure the best practice allocation and use of ICU beds, including triage protocols, cancelling non-essential scheduled acute care services, and sending non-COVID patient services home. It combines insights from two sources:

  • (a) Knowledgebase panel discussions typically made up of an infectious disease specialist, a hospital CEO, and an ethicist, and
  • (b) recent literature reviews at ten week intervals by EthicScan on the ethics of triage decision-making across the globe.

The panelists face five Questions: 

  1. Why are triage decisions made in a hospital?
  2. What mitigation and adaptation strategies will enhance acute care treatment of COVID patients?
  3. What alternative if any is there to flattening the curve as an approach to managing hospital resources?
  4. Are there ways amidst COVID wave two to not – as was the case during wave one– reduce the tens of thousands of procedures that were suspended in order to reserve beds for COVID patients?
  5. What is the single most important change that would allow for better in hospital treatment of all patients during a pandemic?

Ethical Analysis

Ethical decision-making in crisis care hospital situations includes addressing the following challenges:

1. Who gets care: the morality of giving preference to pandemic respiratory illness

2. When do they get care: triage criteria

3. Why do they get care: informed consent

4. Which stakeholders are unfairly dis-enfranchised and/or discriminated against in the allocation of care?

Question One

Empty hospital beds allocated for COVID-19 patients

When the demand for health-system resources exceeds supply, triage decisions must be made. As the spread of COVID-19 places greater demands on health systems, not only have non-urgent, elective and non-COVID procedures been deferred, but also operating rooms and in-patient beds are being emptied before an anticipated peak of pandemic cases. This is seen as necessary preparation to ensure that hospitals and staff are not crippled by a large volume of critically-ill patients presenting within a short time frame.

As wave two worsens with daily detected cases higher than seen in wave one, further triage will be required. The American College of Surgeons has provided guidance to aid in prioritizing cases, but challenges will remain both in this current time of crisis and over the several months after the peak of the pandemic. Experts caution that getting this right will be a challenge because there are several considerations that will need to be taken into account as systems develop long-term strategies for prioritizing a range of competing health-specialty procedures. According to practitioners, such triage decision recommendations fall into one of three stages:

Triage Decisions Before A Pandemic Triage Decisions During A Pandemic Triage Decisions After a Pandemic
Stop all non-urgent operations as soon as possible (if not already stopped) in all ambulatory and non-ambulatory centers. Prioritize lifesaving operations with a clear plan to move to triage based on quality of life years attainable if resources become scarce. Regularly and realistically assess the hospital system’s capacity to expand surgical services.
Define time-sensitive cases within each specialty following standard crisis care criteria. Centrally review time-sensitive cases within each specialty, aligned between specialties, and strictly enforced. Expand surgical services slowly but early.
Define life-or-limb cases before triage based on clear accepted criteria. Reduce priority on certain high resource, necessary procedures if resources become scarce. Maximize capacity by transferring patients to ambulatory centers or other nearby systems that have capacity for treatment.
Constantly review high resource but lifesaving operations such as transplants. Implement strategies to palliate and otherwise care for patients not able to receive urgent intervention due to triage criteria. Rapidly reassess and re-triage patients who have been delayed beyond the recommended time frame.
Develop a framework with the aid of ethicists to consider triage to maximize the quality of life years saved. Provide ample recognition, reward and support for front-line care providers. Prioritize cases and diagnostic tests (e.g. cancer and heart) that have been delayed beyond optimal windows for treatment or have undergone less optimal alternative therapies.
Develop protocols for the non-operative management of common and uncommon emergent, urgent, and elective conditions. Communicate thoroughly and clearly with patients whose procedures are delayed or postponed. Apply second level re-prioritization for sustained but reversible morbidity cases incurred during waiting, prolonged pain, and increasing projected complexity.
Develop pathways to transfer surgical patients to centers with greater capacity if resources become scarce. Delay procedures for patients that are waiting to undergo surgery without direct benefit to health (e.g., minor cosmetic surgeries). Continue to delay operations for asymptomatic patients with a risk of acute deterioration (e.g., infant hernias) but provide good counselling.
Establish a clear process for physicians to present special cases for consideration that do not fit strict triage criteria. Use ambulatory centers to address the burden of delayed before addressing less urgent operations. Maintain COVID-19 surgical care pathways and a COVID-19 operating room for COVID patients who continue to present with conditions requiring surgery.
Prepare for considerable moral distress and frustration among various stakeholders. Provide ongoing provider support during the time of increased demand. Integrate approaches developed during the pandemic into hospital practices for use in future cases with high infectious transmission risks.

 Source: adapted from American College of Surgeons and Annals of Surgery

To improve nurse’s, doctor’s and bioethicist’s  triage performance, hospitals are encouraged to offer regular refresher triage training, encourage collaboration between emergency departments, and continuously monitor difficult cases in order to strengthen the use of triage systems. Principles in best practice application of triage include:

  • involve infection-control specialists, patient’s rights advocates and clinicians in the process
  • physically separate the care of COVID and non-COVID patients
  • discuss, test, support and implement clear, severe crisis care decision-making frameworks.

Question Two

The international literature that reports on specific hospital adaptation and mitigation procedures include the following:

MANAGEMENT CHANGES TECHNOLOGY CHANGES PATIENT CARE CHANGES
Better use natural disaster planning tools Create a more fully networked information system Empower consumers (diet, health, exercise, distancing)
Enhance minimal physical contact Accelerate telehealth/virtual care Maximize remote procedures for non-COVID patients
Review and update triage protocols Invest in mobile units Focus on wellness
Upgrade inventory control Apply artificial intelligence: cloud storage, multi-disciplinary   Invest in serving underserved and at-risk communities
Strategically pool the location of specialized services (US, Canada, Netherlands, Denmark, Australia)   Accelerate testing of new devices and self-imaging technologies Innovate in the area of patient management
Promptly discharge patients to appropriate post-acute care based on health status – home, rehab centre, or nursing home Implement networked digital platforms Group and separate stream COVID patients by underlying critical conditions
Locate hospitals everywhere, anywhere Assess prospective public-private partnerships Send emergency teams into the community: nursing homes
Focus on acute care Invest in touch-free controls for staff and patients Give more control to consumers:  transparency, digital self-diagnosis, home care choices
Invest in prevention services Restrict the use microbial-based building materials Link social services, housing and counselling
Conduct emergency preparedness tests every two to five years Invest in bedside chatboxes Offer better rewards, recognition and counselling for front-line staff
Reduce the size of shared space facilities (cafeterias, lobbies) Segregate the transport of COVID patients Enhance COVID training of front and back office staff
Upgrade PPE procurement and distribution Train staff in infectious disease control Invest in referral pathways

Source: Adapted from routine EthicScan literature reviews

Thankfully, during COVID wave one, Canadian provinces did not come close to swamping available ICU beds though the threat is real—our numbers of ICU beds per capita is inferior to that in other jurisdictions. As reported in EthicScan Blogs, Are We Ready for COVID Wave Two: an Ethical Analysis (September 28) and Rationing Who Gets Care? (April 1), we delayed nearly 200,000 approved procedures which had a huge impact on non-COVID mortality and severity of condition cases.

Question Three

Many hospitals in Canada and the United States have developed and/or applied similar “Crisis Standards of Care” frameworks to use if and when critical care resources become scarce. Under such guidelines, operating room resources are conserved but care decisions may consume other resources and contribute to patient morbidity. Different specialties, such as cardiology and oncology, may require different approaches to triage.

The current consensus is that prioritizing cases that are immediately or urgently lifesaving offers the greatest benefit for lives saved during crisis. This is the current form of triage undertaken across most of Canada and the United States. Under extreme circumstances, triage shifts to consider prioritizing patients for whom the greatest number of quality life years can be salvaged. This form of triage, for example, was enacted in Italian critical care units during wave one, where patients most likely to recover have been prioritized over the sickest.

There has been little sustained, active and transparent public participation or before-the-fact engagement with Canadian governments that enact emergency order edicts involving social distancing, mask wearing, and shutting down businesses and schools.

EthicScan Blogs The Debate Over Governments COVID Decisions Goes Public (October 5) and Cure-vs-Care: Flattening the Curve (March 24) discuss what alternatives there are to flattening the curve as an approach to managing hospital resources.

Question Four

The COVID-19 pandemic has drastically changed surgical and non-surgical priorities in Canada and worldwide. For example, patients with time-sensitive surgical conditions or tumors have been prioritized, whereas patients with surgical conditions that require less urgent management such as asymptomatic hernias or obesity have been postponed indefinitely. This has implications for progression of severity of disease and neglect.

In China, ongoing elective operations and non-essential clinic visits contributed to early rates of in-hospital COVID-19 transmission. In Italy where resources consumed through elective surgery, including personal protective equipment use that left health-care workers vulnerable when the pandemic crested. In Canada, individual experts debate about how best to reduce the recurrence of a need to suspend tens of thousands of procedures due to reserving beds for COVID patient treatment. Within the last month, certain Ontario hospital heads and associations have become more vocal in issuing public statements about such public-policy choices.

Question Five

What is the single most important change that would allow for better in-hospital treatment of all patients? While there are many worthy answers, mine would be ethical clarity. The problem is that application of enhanced ethical decisions in health care is not formed enough to apply robustly or systems-wide.

Bioethics was born in the 1950s and 1960s as a reaction to the atrocities of World War II and extreme violations of human rights in medical research. But it was slower, some might say less successful, in building conceptual and policy frameworks for issues related to justice. Bioethics has spent insufficient intellectual energy in coping with issues related to families, distributive justice, and cultural communities. The discipline started only later to develop meaningful tools for dealing with public-health ethics. COVID has exposed bioethics as needing a dramatic shift towards applications that need better spokespersons, growing recognition and faster implementation.

Conclusion

Hospitals have some unspoken but real degree of moral authority in the community. COVID has been a wake-up call for hospital administrators on how they might and could change:

  • (a) the way they deliver care,
  • (b) how they interact with and support other parts of the system,
  • (c) issuing timely, knowledge-based public studies and advisories on responsible public health policy choices,
  • (d) championing attention to non-institutional providers (like home and palliative health care) where appropriate, and
  • (e) how public health policy could be enhanced.

Events like this pandemic have a high probability of reoccurring, yet hospital leaders who write about and speak to larger health systems choices and solutions are all too rare. The focus of expert opinion responses on “new normal” health care in hospitals typically has largely been mitigation, rather than transformational.

Need More Answers?

Subscribe to the EthicScan Knowledgebase for in-depth research and the opportunity to share information with industry experts, policy-makers and other health-care professionals.

Learn more here

More EthicScan Resources

EthicScan Blog – Cure vs Care:
https://ethicscan.ca/blog/2020/03/24/cure-vs-care/  ###

EthicScan Blog – The Future of Hospital Systems Post COVID:
https://ethicscan.ca/blog/2020/06/08/the-future-hospital-systems-post-covid/  ###

EthicScan Blog – Leadership Recover – The Future of Hospitals:
https://ethicscan.ca/blog/2020/10/16/leadership-recovery-the-future-of-hospitals/ ###

EthicScan Blog – Rationing Who Gets Care:
https://ethicscan.ca/blog/2020/04/01/rationing-who-gets-care    ###

comments on these Blogs are found in the Knowledgebase

Further Readings

Annals of Surgery – Approaching Surgical Triage During the COVID-19 Pandemic:
https://journals.lww.com/annalsofsurgery/Fulltext/2020/08000/Approaching_Surgical_Triage_During_the_COVID_19.9.aspx

Forbes – A Game Plan For Rewiring The Hospital For The Post-Covid Era:
https://www.forbes.com/sites/forbestechcouncil/2020/07/31/a-game-plan-for-rewiring-the-hospital-for-the-post-covid-era/?sh=660743456f25

BMC Emergency Medicine – A review of triage accuracy and future direction:
https://bmcemergmed.biomedcentral.com/articles/10.1186/s12873-018-0215-0

New York – Intelligencer: What Coronavirus Triage Could Look Like in American Hospitals:
https://nymag.com/intelligencer/2020/03/what-coronavirus-triage-could-look-like-in-u-s-hospitals.html

LinkedIn – The Need for a Covid-19 “Triage”​ Recovery Strategy for National PPP Initiatives:
https://www.linkedin.com/pulse/need-covid-19-recovery-triage-national-ppp-david-baxter/

New England Journal of Medicine – Covid-19 Crisis Triage — Optimizing Health Outcomes and Disability Rights:
https://www.nejm.org/doi/full/10.1056/NEJMp2008300

David Nitkin
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