ICU Triage Protocols: An Equitable Solution

Surging COVID-19 cases in recent weeks have led to intensive care units across the country nearing capacity. In turn, this has prompted governments and health systems to review their existing ICU triage protocols for allocation of scarce ventilators and critical care resources.

Douglas White, MD, MAS and Bernard Lo, MD argue in the American Journal of Respiratory and Critical Care Medicine for the adoption of three strategies to mitigate health inequities during ICU triage. Their paper, ‘Mitigating Inequities and Saving Lives with ICU Triage During the COVID-19 Pandemic,’ provides a practical triage framework that incorporates the three strategies and attends to the twin public health goals of promoting population health and social justice.

“The pandemic has laid bare the deep inequities in society and disproportionately disadvantaged the poor and Black, Latinx, and Indigenous communities,” said Dr. White, who is the UPMC Endowed Chair for Ethics in Critical Care Medicine. “If we don’t factor health inequities into revised policies for ICU triage, we’ll simply be compounding these inequities.”

Three strategies to mitigate health inequities during ICU triage

  • Introducing a correction factor into patients’ triage scores to reduce the impact of baseline structural inequities
  • Giving heightened priority to individuals in essential, high-risk occupations
  • Rejecting use of longer-term life expectancy and categorical exclusions as allocation criteria

A range of alternative allocation strategies—including narrowly prioritizing by chances of survival to hospital discharge or using a random lottery to give all patients in need an equal chance of ICU treatment—have been suggested. Yet Dr. White believes that both those approaches are seriously flawed, in part because neither approach will actually mitigate disparities.

He says that ICU triage policies should simultaneously promote population health outcomes and mitigate health inequities. These ethical goals are sometimes in conflict, which will require balancing the goals of maximizing the number of lives saved and distributing health benefits equitably across society.

Douglas White, MD, MAS is professor of Critical Care Medicine, Medicine, and Clinical and Translational Science. He is the director for the Program on Ethics and Decision Making in Critical Illness in the Department of Critical Care Medicine at the University of Pittsburgh.

Bernard Lo is professor of Medicine Emeritus and director of the Program in Medical Ethics Emeritus at UCSF and past president of the Greenwall Foundation in New York.