Detailed studies of U.S. disaster preparedness offer recommendations

illness severity. Patients’ SOFA scores would be evaluated if their risk of hospital mortality is 80 percent or greater. Life-limiting illnesses that would exclude patients from receiving scarce critical care resources include conditions such as:

• Severe trauma
• Severe burns in certain circumstances
• Cardiac arrest (unwitnessed or witnessed events that don’t respond to electrical therapy)
• Severe baseline cognitive impairment
• Metastatic malignancy
• Advanced, irreversible neurological events or neuromuscular disease
• End-stage organ failure
• Age above 85 years

The task force recommends that a triage officer — ideally a highly experienced surgeon who has outstanding leadership and communications skills — review all patients’ exclusion and inclusion criteria. “He or she is expected to make decisions that benefit the greatest number of patients given potentially limited resources, even though these decisions may not necessarily be best for any individual patient,” the task force wrote. Attending clinicians will inform patients and family members of the triage officer’s decisions, and a triage team made up of clinical care nurses, respiratory therapists, and/or pharmacists will update the triage officer and assist with rationing decisions, the authors wrote. Decisions to reallocate critical care resources among patients will require a high degree of transparency and regular reviews to ensure that established processes are being followed. Patients who are excluded from critical care should receive palliative care, the task force said. “During challenging times, it is imperative to uphold the ethical commitment to alleviate discomfort without intentionally hastening death; euthanasia is not acceptable,” they wrote. “Thus, it is mandatory that mass disaster preparation anticipates palliation for large numbers of individuals.” The group pointed out that the triage process only applies to patients in acute care settings and that rationing should apply to all acute-care patients, even if their condition isn’t related to the disaster events. They identified several areas that would benefit from more research and care protocols. For example, they said illness severity and scoring systems need more refinement, particularly for pediatric patients. Also, they wrote that more efforts are needed to train healthcare providers about critical care triage and that strategies are needed for communicating rationing concepts to the public and to the families affected by the triage decisions.

Hick said now that critical care experts have released their assessments, surge capacity recommendations, and resource allocation guidance, the next step is for states to address liability issues that could protect caregivers and health systems when disasters reduce normal levels of care. “I hope also that staring down the actual triage criteria from a large group will force states and the federal government to confront these issues and the scarcity of healthcare issues,” he said. The task force does not have any more meetings scheduled, but Hick said there are signs that the international community is willing to take on critical care triage issues, such as a research push for better predictive tools for triage.