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Triage – the act of ranking patients based on their odds of survival – is usually reserved for wartime. Civilian doctors rarely resort to it.
But the new reality of COVID-19 has forced medical professionals and government officials to wrestle with how it should be done in local hospitals. If 10 people need a ventilator, but only five are available, who gets the machines?
Officials in San Diego – and across California – are rushing to create a uniform plan that would answer exactly that question with some measure of objectivity. Officials declined to say when that plan might be available or when it might receive public vetting.
While some other states, such as New York and Washington, do have triage plans in place, California does not. If a surge happened in San Diego hospitals today, patients might not be triaged in the same way at different hospitals throughout the region – opening the door to inequity in who gets critical life-saving resources and who does not.
San Diego’s curve has flattened somewhat in the last week, but it is still possible that local hospitals could be overwhelmed with more patients than they have the ability to treat, according to modeling previously released by county officials.
“Hopefully we won’t ever need a plan like this, but we have to be ready,” said Dr. Lynette Cederquist, a doctor with UC San Diego Health, who is currently working on multiple triage plans.
Most triage plans work in the same way, she said. Patients are ranked based on their chances of short-term and long-term survival. A patient with underlying conditions – such as dementia or cancer – would have less chance of long-term survival. That patient would receive less priority in the event of a ventilator shortage.
Some patients would also receive higher priority – pregnant women and frontline health care workers, for instance, said Cederquist.
In the event of a tie, some kind of lottery system would be used to decide which patient receives critical care treatment, said Cederquist.
The plans Cederquist is working on do not take age into account.
“There was significant debate about this [age] piece, as most people felt prioritizing a younger person would be ethically supported, and likely would be something society would support, but legal input felt it would violate legal restrictions of age discrimination,” Cederquist wrote in an email.
She noted that many older patients have underlying conditions, which would inherently lower their priority.
During a resource crisis, hospitals would set up triage teams. The teams would be responsible for assigning a ranking – which would likely be point-based – to each patient. Doctors who work on the triage team do not treat patients and vice-versa, Cederquist said.
The local triage plan would not just apply to ventilators. It would also apply to other machines that could be in short supply in a worst-case scenario, such as those that can assist heart or kidney functions, Cederquist said.
Cederquist is simultaneously involved in creating several triage plans. Once the plans are completed, it is unclear exactly which one will take precedence in San Diego County.
She is part of one working group that involves representatives from local hospitals, as well as representatives from the county Health and Human Services Agency, that is working to create a plan that San Diego hospitals could follow.
Cederquist is also on a committee working to create a plan for the entire University of California system of hospitals.
State officials are also working to create their own statewide plan, Cederquist said. State officials declined to say when the plan might be finished.
It’s unclear how such plans might apply to a hospital chain such as Kaiser Permanente, which has hospitals nationwide and locally.
Cederquist said all the plans she is working on are close to being finalized. She also said the state guidance is expected soon.
Dr. James Schultz, president of the San Diego County Medical Society, said it’s important to have the plans in place, in the event of a worst-case scenario. In that situation, individual doctors should never be tasked with making case-by-case decisions about who gets critical care, he said.
Schultz said the local Medical Society has a bioethics committee, which has helped inform the county triage planning process.
Cederquist said she hopes any county or statewide plans will seek public input, as some plans in other states have.
“There’s definitely a sense of the importance of getting community buy-in” from people on the county work group, said Cederquist. The plan needs to be “supported by community values.”
County officials declined to say whether their triage planning process would include public input.
“Discussions here have taken place in advance of the expected release of guidance from the state, guidance which the hospitals will likely follow,” wrote county spokesman Michael Workman, in an email.