Criteria for ICU admissions if Hospitals run out of bed

ICU frontline doctor Dr Enda O’Connor speaks about the deciding factors that comes into deciding whom should be admitted to the ICU and who mustn’t.

He said that there are no mathematical formulas around but what we know is at the centre of making decisions about patients coming in or not coming to intensive care are several key things that have to take into account. The first thing is really the severity of their illness. The acute illness that they have at the moment that we see them.

‘Number one, they might not be unwell enough to need an intensive care bed or, potentially, they may be too unwell and not be a sort of patient that would respond to therapy in intensive care,’ he added.

According to him the second thing you have to take into account, is the patient’s wishes.

The third is the overall condition of the patient independent of Covid. So, have they got any major other medical problems or clinical problems that might mean that they would really quite poorly respond to life-support therapy. “I mean, chronic heart disease, chronic lung disease, chronic liver disease, advanced cancers, those sorts of things,” he added.

The following are direct extracts from the guidelines approved by NPHET last April, where ICU bed capacity reached its limit.

ADMISSION 

‘In emergency and non-emergency situations, it is not ethically appropriate to offer intensive care to every patient, since intensive care will not provide benefit to some patients who are seriously ill or dying. Access to intensive care should generally be reserved for those patients in whom a good outcome may be expected. In line with the principle of minimising harm, it may be necessary to impose stringent restrictions on ICU admission during a pandemic in order to ensure that the available resources are used to achieve the best possible outcome at a population level.’

FAIR ALLOCATION 

‘WHERE intensive care resources become limited, it is ethically necessary, justifiable and proportionate to have mechanisms/decision tools in place to enable healthcare professionals to triage and prioritise access to those resources. In line with the ethical principle of fairness, there should be processes to guide the distribution of burdens and benefits across members of society, so that no individuals or groups shoulder a disproportionate burden or benefit… relative to others.’

REGULAR ASSESSMENTS 

‘Part of the process of prioritising critical care in a pandemic involves the review of the effectiveness of care for patients who have already been admitted to an ICU. If a patient’s condition or prognosis deteriorates, or if it does not improve following admission, decisions regarding the continuation or potential withdrawal of intensive treatment will need to be made. Where a patient is likely to be admitted to an ICU, this should be preceded by an explanation that, in a pandemic situation where resources are severely limited due to increased demand, critical care will be provided on the premise that continuation of treatment will be based on regular assessments of the patient’s response to treatment.’

APPROPRIATE RESUSCITATION

‘It is important to recognise that the pressure arising in relation to the availability of intensive care resources during a pandemic could have a direct impact on other clinical decision-making within a hospital for patients with or without Covid-19. For example, if, due to his/her condition and prognosis, a patient would not meet criteria to access intensive care during the pandemic, it may not be appropriate to provide that patient with cardiopulmonary resuscitation (should s/he collapse) since the required follow-up care in the intensive care unit would not be available. This should be discussed with patients and their families. It would be important that any decisions taken in such scenarios are appropriately recorded, e.g. in a do-not-attempt-resuscitation order and communicated to the patient and/or their family.’

HIGHER THRESHOLD 

‘As pressure increases on intensive care capacity, it may be necessary for a higher threshold to be applied in relation to which patients can access intensive care treatment.’

SHARED RESPONSIBILITY 

‘It is vital that decisions relating to the allocation of life-saving equipment do not become the responsibility of single individuals. Decisions to prioritise or deny access to critical care interventions should ideally always be discussed by at least two senior clinicians with experience of respiratory failure in ICU (where possible).’

NO SINGLE FACTOR 

‘Factors such as frailty or the existence of co-morbidities should only be considered relevant in triage decisions insofar as they will have an impact on the patient’s potential to benefit from ICU admission and remaining survival time after discharge. No single factor (e.g. a person’s age) should be taken, in isolation, as a determining factor and decisions should not be made arbitrarily or in such a way as to result in unfair discrimination. In the interest of fairness and to protect against unjustified discrimination, it is important that clinicians apply a consistent approach to considering the predictors of outcome for all ICU admissions.’