This micro-learning will focus on managing shortages. We'll discuss principles of allocation and processes in crisis situations. We'll first review crisis standards of care, then discuss principles of allocation, processes for allocation, and review Society of Critical Care medicine guidance on this topic. Crisis standards of care evolve as resource scarcity evolves during a public health emergency. Under conventional care, institutions have usual availability and uses of supplies, staff, and space. They're able to provide care according to their usual standard of care. In contingency care, there are anticipated shortages in supplies, staff, and space. Institutions begin to alternatively use these resources in functionally equivalent ways. This may include rescheduling elective procedures and use of functionally equivalent personal protective equipment. They're still able, however, to provide care according to the usual standard of care. Under crisis conditions of care, the standard space, staff, and supplies are no longer available, and alternative methods and interventions that have been implemented are no longer sufficient to maintain needs. In this phase of care, institutions provide a standard of care that is sufficient, given the circumstances and resources that are available. Several conditions must be in effect for crisis standards of care to be implemented. A public health emergency must have been declared and crisis standards of care activated by institutional or local authorities in accordance with government guidance in this area. Attempts to mitigate shortages must have been expended, and federal support may have been requested but not yet available. When crisis standards of care are in place, allocation decisions may need to be made regarding the use of scarce resources. These allocation decisions and processes apply while the crisis standard of care is in place and must apply equitably and fairly across all conditions presenting for ICU care, not just whatever triggered the crisis state. Several allocation principles underlie allocation approaches. These are guided by planning, process, and public engagement. In general, allocation approaches respect the underlying idea that every life is worth saving. Planning for allocation during crisis standards of care should be approached with the idea of preventing scarcity and reallocating other resources when possible. Processes for allocation should respect that decisions to deviate from usual approaches to care should not be made at the bedside, that clear, well-defined allocation decision trees should be developed by a group of institutional leaders, providers with subject matter expertise, those with ethics training, and community representatives, and that these processes should be based in ethical principles. There are several goals of allocation strategies. First, these strategies should be reasonable, meaning that they are based on evidence, principles, and values that stakeholders can agree upon and that are relevant to meeting health needs in a crisis. These decisions should be made by people who are credible and accountable. Second, they should be transparent, meaning that decisions are open to review and scrutiny on a publicly available basis for decisions. Third, they should be inclusive, meaning that they are informed by stakeholder views with stakeholders engaged in the process. Fourth, they should be responsive, meaning that they can be revisited and revised and that there is a process for resolution or appeal of disagreements or disputes. Finally, they should be accountable, as discussed, and that decision makers are answerable for the decisions. Several approaches to allocation have been described. The following slides summarize individual approaches to allocation and are not meant to support a given strategy as the appropriate strategy for each institution will be based on their local availability of resources, priorities, values, and community engagement. This slide describes approaches that aim to treat people equally in provision of resources. The first approach, a lottery approach, is a random allocation of resources. This approach is hard to corrupt as it treats everyone equally. However, it does not take into account other relevant factors such as likelihood of benefit from the use of resources. A first-come, first-serve approach would treat those patients who present first with services until they are no longer available. This preserves the doctor-patient relationship and requires little information about patients. However, it may not optimize resource utilization providing maximal overall benefit. Further, it could disadvantage those who don't have the knowledge to present early when resources are still available. Other approaches give priority to different groups. The youngest-first or rescue approach gives priority to those most in need or at risk of dying. This has the advantage of following the general rule of rescue by considering the worst-off overall. However, it could falsely assume that scarcity is temporary and it does not take into account the likelihood of benefit, thereby not ensuring that the overall maximal benefit is achieved. The life-cycle principle or youngest-first approach gives each person an equal opportunity to live through various life phases by prioritizing those who have not yet lived through those phases. This has the advantage of not considering one's intrinsic social value or worth. However, it could unjustly discriminate against older people. Several allocation approaches strive to promote the greatest utility or maximize a total benefit with the use of scarce resources. The chance-of-survival approach, saving the most lives, is based on the chance of a patient surviving their current illness and considers short-term survival as the greatest factor. This balances efficiency while avoiding irrelevant issues and has the goal of saving the most lives. However, the prediction models on which short-term survival are made are often disease-specific and may be poor prognostic indicators. Additionally, it could ignore other principles of justice. Maximizing quality-adjusted or disability-adjusted life years focuses on maximizing quality of life. However, this is not feasible in a crisis situation as it requires a great amount of qualitative, value-laden conceptualization and judgment. Maximizing life years is based on prioritizing those who will live longer if saved. This has the advantage of saving more years of life overall. However, it may be difficult to determine how to maximize life years and may exclude some with limited life expectancy but good quality of life. Finally, some allocation approaches promote or reward social usefulness. For example, the social instrumental value approach is based on one's societal worth or ability, including those who contribute to society. This has the advantage potentially of ensuring an adequate workforce and is future-oriented in its approach. However, it is difficult to determine who is indispensable and this is a very value-laden concept. Additionally, we cannot necessarily determine who will be of most value in the future. Finally, the reciprocity approach is based on the thought of those who will be compensated for their effort or sacrifice. This has the advantage of rewarding those who implemented important values in a crisis, for example, research participation. However, this can be vulnerable to abuse and can direct resources away from the areas of greatest need. When implementing an allocation approach, there are several processes to develop. First, a triage team should be established which determines who will make decisions and how. The disclosure of decisions to patients and families and clear and equitable procedures for appeal. Processes to plan for treatment to offer those who do not receive scarce resources must also be developed. Additionally, there must be a plan for supporting providers who must implement allocation schemes, especially when these deviate from usual standards of care as this may generate significant moral distress. The triage team must develop the actual process of triaging and assignment of priority scores for use of scarce resources. Finally, there must be procedures to review the decisions of triage teams and to appeal them and a process for revising the allocation approach in changing circumstances. Triage decisions should be made separate from the clinical team to promote objectivity, avoid conflicting obligations, and lessen moral distress. Committees rather than individuals should be considered to conduct triage processes. Teams should include acute care physicians such as critical care or emergency care, acute care nurses or advanced practice providers, contact experts depending on the policies such as infectious diseases, hospital administrators, community members, or palliative care providers. Ideally, teams will be an odd number to avoid the need for tiebreakers. Decisions made by triage teams may be disclosed by the triage teams or their representatives, the clinical team or attending physician for the patient, or collaboratively between these groups. The approach to take may vary by institution or by individual circumstances within an institution. When disclosing, support resources ought to be considered including palliative care, spiritual care, social work or mental health support, and ethics for moral distress. Prior to implementing a triage plan, triage triggers and exclusion criteria for critical care support ought to be considered. Triage triggers are determined by implementation of crisis standards of care, generally at the institutional level in line with local and state health officials and determinations. Triage should recognize that public health crises are regional, not institutional in nature, and as such, resource sharing within the region ought to be optimized to the degree possible prior to instituting triage at any individual institution. Exclusion criteria for critical care could exist in allocation approaches. These may include a consideration of goals of care at the time an individual is presenting for critical care resources or pre-existing advanced care plans including DNI and DNAR. These ought to be reviewed in a current goals of care discussion at the time of presentation. It should be recognized that categorical exclusion criteria raise justice and fairness concerns. Any exclusion should avoid discrimination based on race, gender, disability, sexual orientation, religious beliefs, citizenship or socioeconomic or insurance status. Anticipated immediate or near-immediate death regardless of the provision of optimal critical care support may be considered as an exclusion criteria. Allocation approaches will likely involve some form of triage scoring. This may include both initial scoring for initial allocation of a scarce critical care resource and reassessment for consideration of reallocation of resources. Different factors will weigh into priority scoring systems. These will depend on allocation principles used and will vary by institution based on the principles they choose to implement. Informed by local considerations such as values, community engagement and resource availability. Multiple approaches may use several different allocation principles within the same scheme. For example, an approach to maximize total benefit may include both considerations for short and long-term survival. Short-term survival may be predicted by scoring systems to prognosticate mortality. Longer-term survival may also include comorbid conditions and clinical judgment. Scoring systems will need to assign an individual score and then consider whether to utilize raw scores or categories in distinguishing individuals. The timing of the initial score as well as reassessment also must be determined. When individuals have a similar raw or categorical score, tiebreakers may be implemented. These might include life cycle, social value such as that prioritization of health care workers or essential workers and lottery or random systems among others. Different scoring systems have been suggested for different situations. Sample scoring systems for the adult, pediatric and neonatal populations are shown here. However, many scoring systems are not validated for clinical use and in particular for the clinical application in which they are being applied. Moreover, the predictive value of scoring systems within institutions may vary. When possible, institutions should consider local modeling and analysis of the most appropriate measure using local morbidity and mortality data. For both short and long-term mortality, comorbidities may be included. Specific comorbidities, however, may be difficult to equate among neonates, children and adults and may warrant separate considerations for these groups. The consideration of comorbidities' impact on immediate survival and one-year survival may be utilized by many systems that prioritize short-term survival. Depending on predictive mortality scores used, some raise concern about the inclusion of comorbidities as these factors may alter predictive mortality scores and then may be double-counted as comorbidities. For this reason and others, subspecialist confirmation of comorbidities and the use of clinical judgment may be helpful. When allocation schemes are implemented, there must be a process for reviewing, appealing and managing individuals who cannot receive critical care resources. Triage decisions should be reviewed at regularly scheduled intervals to ensure fair, consistent allocation by triage teams. Appeals processes for initial and reassessment scoring should also be in place. For initial decisions, appeals may be limited to prognostic errors. Evaluative care and other supportive care should also be maximized when critical care resources are not available. While the allocation principles outlined above can be applied to shortages in many kinds of resources, a special note about cardiopulmonary resuscitation is warranted. CPR can also be considered a resource as it requires a large number of providers and increases risk of exposure to providers. The duty to perform CPR is not absolute and appropriate personal protective equipment should be utilized. While there is a duty to presume desire for CPR, if no physiologic benefit is expected, institutions may consider withholding CPR when this is in line with local government authorization and state law. In addition to the principles outlined in this discussion, SCCM Ethics Committee also offers guidance and recommendations. An algorithm outlining the approach to allocation of scarce resources is provided here. It begins with patient assessment using prospective methods of predictive scoring systems with consideration of comorbidities and clinical judgment involving the primary team and a triage committee. From here, individuals will be deemed either too well for critical care, too sick for critical care, or of likelihood to benefit from critical care. For those who are too well, they would proceed with general medical management with reevaluation over time for critical care needs. For those who are not expected to survive even with maximum therapy, critical care would not be offered. This decision should be disclosed to the patient and family with the best medical management provided and an offer of palliative care. A goals of care discussion would ensue with a decision either to provide palliative care depending on family goals or to continue non-critical care medical management with or without the addition of palliative care. For those likely to benefit from critical care, the allocation would depend on availability of resources. If resources are available, the patient should receive critical care resources. If they are insufficient, patients would be selected via a lottery, and those not selected in the lottery would be placed on a waiting list. When no resources are available, patients would also be placed on a waiting list. The SCCM recommendations and guidance, as well as all of the principles discussed in this learning session, are based on the ideas of fairness and equity in the allocation of scarce resources. Multiple approaches to allocation can be justified based on these principles, depending on the values and resources within local systems.

managing shortages

crisis situations

allocation principles

crisis standards of care

resource allocation