Influenza pandemic will pose tough choices for use of mechanical ventilation

Triage plan seeks to set guidelines before a crisis occurs

Amidst all the talk about the risk of an influenza pandemic, little has been said about the difficult decisions that would have to be made in an overwhelming health care crisis. An article in the February issue of Academic Emergency Medicine, the Official Journal of the Society for Academic Emergency Medicine, outlines a sample set of guidelines for prioritizing the use of a piece of equipment likely to be in short supply in a pandemic: mechanical ventilators.

Drs. John L. Hick and Daniel T. O'Laughlin of University of Minnesota propose a concept of operations and a set of suggested guidelines for triage of mechanical ventilators in a pandemic or bioterrorist attack. "When a large-scale pandemic does occur, we're simply going to run out of resources," comments Dr. Hick. "We need to be talking now about how we are going to allocate scarce resources to the patients most likely to benefit from them."

Drs. Hick and O'Laughlin developed their proposal after a recent drill showing that an epidemic affecting ten percent of the Minneapolis area would lead to a "rapid and critical shortfall" in the supply of mechanical ventilators. "Despite a surge capacity of between 2,500 and 3,500 beds in the area, there were 16 ventilators available in our regional system," says Dr. Hick.

The proposal calls for a set of general guidelines to be developed in advance by a team of public health officials and medical experts. The guidelines would be subject to review by a separate group, including elected officials and members of the public.

The guidelines would be arranged in tiers--as resources are exhausted, another, more stringent set of criteria would come into effect. At each level, the criteria would be based on clinical indicators of the patient's chances or survival and likely use of health care resources, with the objective of directing scarce resources to the patients most likely to benefit.

In a crisis, the guidelines would rapidly be tailored to the specific situation, then issued as part of an emergency order. "The goal would be to promote consistency between hospitals and regions," says Dr Hick. "Across the board, resource allocation would be as equal as possible. The concept is distributive justice--doing the greatest good for the greatest number of patients."

In Minnesota, the process is underway, according to Dr. Hick. "A set of general guidelines has been developed by a science team and vetted by a guidelines review group. Reception has generally been very positive, including discussions of the ethical issues involved with community groups."

Even more important than the specific plan that emerges, Dr. Hick believes, is the establishment of a decision-making process. "We need to start talking about this now and develop a fair process so that, in a crisis, a mechanism is in place to apply the best science we have to make the best use of the available resources. Although our plan is not definitive, we hope it will serve as the starting point for a discussion that needs to be had."

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About the Society for Academic Emergency Medicine (SAEM)
The mission of the SAEM is to foster emergency medicine's academic environment in research, education, and health policy through forums, publications, inter-organizational collaboration, policy development, and consultation services for teachers, researchers, and students. (http://www.saem.org)

About Elsevier
Elsevier is a world-leading publisher of scientific, technical and medical information products and services. Working in partnership with the global science and health communities, Elsevier's 7,000 employees in 77 offices worldwide publish more than 2,000 journals and 1,900 new books per year, in addition to offering a suite of innovative electronic products, such as ScienceDirect (http://www.sciencedirect.com/), MD Consult (http://www.mdconsult.com/), Scopus (http://www.news.scopus.com/), bibliographic databases, and online reference works.

Elsevier (http://www.elsevier.com/) is a global business headquartered in Amsterdam, The Netherlands and has offices worldwide. Elsevier is part of Reed Elsevier Group plc (http://www.reedelsevier.com/), a world-leading publisher and information provider. Operating in the science and medical, legal, education and business-to-business sectors, Reed Elsevier provides high-quality and flexible information solutions to users, with increasing emphasis on the Internet as a means of delivery. Reed Elsevier's ticker symbols are REN (Euronext Amsterdam), REL (London Stock Exchange), RUK and ENL (New York Stock Exchange).


Last reviewed: By John M. Grohol, Psy.D. on 21 Feb 2009
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