According to the critical care triage document put together by Alberta Health Services to manage an overrun of intensive care patients amid the COVID-19 pandemic, health-care workers are to prioritize incoming patients who have the greatest change of survival.
“This is a very complex document,” Dr. Noel Gibney, the co-chair of the Edmonton Zone Medical Staff Association’s Strategic COVID-19 Pandemic Committee told Global News Friday afternoon.
“This is very well designed and that’s what make it so challenging, I think, to implement.”
But, even with these guidelines, random selection could still be what the health-care system has to fall back on.
The critical-care triage document says patients who need care in the ICU are to be admitted on a first come, first-served basis, but if two or more patients with equal survival likelihood arrive at the same time, “random selection will be used.”
Health-care workers would be directed to prioritize patients who have the greatest likelihood of overall survival and patients who are “most likely to have a positive outcome with the least use of critical-care resources, either by intensity or duration.”
“Incremental survival differences are based on medical assessments of the patient only and not personal or group characteristics of the patient (i.e. age, sex, race, disability, national or ethnic origin, colour, religion),” the document reads.
According to the guidelines, there are two phases of triage.
Phase 1 would be implemented if Alberta hits 90 per cent of a benchmark number, while Phase 2 would be put in effect if the province were to reach 95 per cent of that same number.
In Phase 1, health-care workers would use a series of tools to estimate whether someone’s likelihood of death in the ICU and one year after would be 80 per cent or over. If it is, they would be refused admission to the ICU at that time.
In Phase 2, the threshold is over 50 per cent likelihood of death.
Pediatric triage will only be considered in Phase 2, the guidelines say.
For example, Gibney said, say you have three people come into the hospital at the same time and they’re all critically ill. If one person has a very good chance of survival, someone is in the middle and the third person probably has a fairly high chance of dying, under the triage system the first person would be given full critical care, the other two would likely never be given the chance to receive that same care.
“That’s really what it comes to,” he said. “And then the real distress comes from having to explain to that individual’s family why, instead of getting critical care, they’re going to a medical ward with a very high probability of dying, or just going straight to palliative care.”
It’s such a change to how health-care workers do things now that it would cause “severe moral distress,” Gibney said, but also would take health-care workers away from providing that critical care, potentially changing how all care is administered.
“Individuals who normally spend their time treating patients and organizing tests, getting medication sorted out, getting people on ventilators, they’re going to be looking at documents to see does this individual fit or not fit, and then spending their time arguing with families who are very upset that it’s being suggested that their loved one shouldn’t be admitted to the ICU.”
While the document is not controlled by Alberta’s chief medical officer of health, Dr. Deena Hinshaw talked about it during her update on Thursday.
“I know discussions of these protocols can create anxiety for many people.”
The document has been worked on since the pandemic began, Hinshaw said, and is based off lessons learned during the 2009 H1N1 pandemic, a document Gibney worked on.
“These protocols are a last resort and can seem scary, but it is important that this work be undertaken as a precaution and that the necessary health-care professionals have an understanding of what these protocols mean,” she said.
Hinshaw stressed Alberta is not at the point of needing this protocol and said she hopes the province never gets there, but said the planning needs to be done.
According to Gibney, if the numbers don’t come down, Alberta could have to implement the triage plan in about three weeks.
On Friday, Alberta Health announced there were 649 Albertans in hospital with the novel coronavirus, with 152 of those people receiving care in the ICU.
An additional 2,007 new cases of COVID-19 have been confirmed over the last 24 hours.
The protocols would be activated at the discretion of the AHS CEO and the executive leadership team and would be in effect in all health-care facilities and critical care units in Alberta.
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