Intensive care medicine: triage under resource scarcity – chronology

The latest version (V4), as well as other relevant documents, and background information can be found here.

 

 

The revision of the appendix was prompted primarily by changes to the intense pressures on Switzerland’s ICUs: unlike the situation during the first waves of the Covid-19 pandemic, ICU treatment is increasingly required by younger, previously healthy patients and not by elderly people with underlying conditions.

 

The medical-ethical principles underlying the triage guidelines remain unchanged, including equity: resources are to be allocated without discrimination. Characteristics such as age, sex, disability, social status, or vaccination status are not to be used as triage criteria. Respect for the value of each individual life is only equal if no distinctions are made on the grounds of individuals’ opinions, decisions or actions.

 

The overarching goal of saving as many lives as possible also remains unchanged. The short-term survival prognosis remains the primary criterion for triage decisions.

 

In the updated version, it is now explicitly stated that the expected effort associated with intensive-care treatment is also to be taken into account. With the same survival prognosis, interventions offering the prospect of success within a short time should thus take precedence over interventions which will only be effective after an extended period of ICU treatment.

 

 

The latest version of the appendix (3.1) clarifies in more detail the principle of the short-term survival prognosis, which is crucial for triage decisions. For example, it is more explicitly emphasised that the aim is always to make decisions in such a way as to ensure that as few people die as possible. Also highlighted is the need for careful consideration of, and re-evaluation of treatment in the light of, the patient’s wishes.

 

In addition, legal aspects are clarified: the discussion of the unacceptability of age, disability and dementia as criteria for triage decisions, as well as the application of the Clinical Frailty Scale, was not sufficiently detailed in the previous version, which gave rise to some misunderstandings. These sections have now been expanded or rephrased, partly in consultation with the relevant organisations.

 

Additionally taken into account is the experience that – despite an increase in ICU beds, the suspension of elective procedures and the involvement of the national body responsible for coordination of patient transfers – application of the guidelines may become unavoidable at the local or regional level before the threshold for triage decisions has been reached at the national level.

 

The recommendations for the work and decision-making of ICU professionals (Sections 4.3 and 4.4) are essentially unchanged, although they have been clarified on the basis of experience accumulated during the pandemic.

 

 

One key change concerns the national coordination body which has since been established by the federal authorities. This is to ensure that optimum use is made of all ICU treatment capacity available across Switzerland.

 

One important clarification concerns age. As in the previous version, it is stated that age in itself is not to be used as a triage criterion; the same applies to disability or dementia. Such factors may, however, be indicative of a person’s general physical condition. To allow this to be better evaluated, the guidelines now also take frailty into account. The (validated) 9-point Clinical Frailty Scale represents an additional useful tool.

 

Additional points have been included in the list of triage criteria for ICU admission/continuation of ICU treatment (Sections 4.3 and 4.4).

 

 

The two stages (A and B) defined in the Box on page 4 of the guidelines remain fundamental:

 

Stage A: ICU beds available, but capacity limited
→ Admission triage/resource management through decisions on discontinuation of treatment

 

Stage B: No ICU beds available
→ Admission triage/resource management through decisions on discontinuation of treatment

 

Clarifications

Stage A: New wording for malignant disease: rather than “metastatic malignant disease”, the guidelines now refer to “malignant disease with a life expectancy of less than 12 months”.

 

Stage A: Distinction between existing and newly arising organ failure. The decisive factor is not whether the patient already has an organ failure on admission, but the occurrence of a new significant organ failure.

 

Stages A and B: Refinement of the triage criteria for patients with COPD.