ACEP COVID-19 Field Guide

Author: Sandra Schneider, MD, FACEP, Associate Executive Director for Clinical Affairs, American College of Emergency Physicians

Planning 

It has long been known that during a pandemic or major disaster that a shortage of ventilators and other life-sustaining devices could occur. The triaging of ventilators should occur only when the hospital, region, or nation is operating in crisis mode. Ideally, planning for such an event should take place in advance and involve hospital personnel, the ethics committee, and even members of the public. Preplanning mitigates the enormity of the decision that must be made by the physician caring for the patient.

Ventilator acquisition 

As ventilators become scarce, attempts should be made to increase the number of devices available. The Federal Government is working with industries to produce more units; however, it is clear that this solution will take time. In the meantime, hospitals should create a communication system or dashboard to locate available units within the region. Ventilators used on animals are identical to those for humans, so veterinarian options should be explored. 

It is possible to ventilate more than one patient (i.e., up to four patients) with a single ventilator. While the Society of Critical Care Medicine opposed this option in the “Consensus Statement on Multiple Patients Per Ventilator,” other agencies offer this as an option, including the: 

• US Public Health Service Commissioned Corps in “Optimizing Ventilator Use During the COVID-19 Pandemic”

Ventilator allocation

In other countries faced with a ventilator shortage, guidelines for intubation were based on projected survival from COVID-19. These guidelines take into account the patient's age and comorbidities as well as the survival data from China. 

Perhaps the best plan on ventilator allocation open to the public is New York State’s “Ventilator Allocation Guidelines.” 

Other documents discuss ventilator allocation over a larger geographic region, including the: 

• Dallas County Medical Society’s “North Texas Mass Critical Care Guidelines”;
• North Texas Mass Critical Care Task Force’s “North Texas Mass Critical Care Guidelines Document: Hospital and ICU Triage Guidelines for Adults”; and 
• North Texas Mass Critical Care Task Force’s “North Texas Mass Critical Care Guidelines Document: Hospital and ICU Triage Guidelines for Pediatrics.”

It is difficult, if not impossible, to have all the necessary facts at hand when making the decision regarding intubation and ventilator use. Most scoring systems are based on the sequential organ failure assessment (SOFA) score, which is unavailable in the emergency department. The New York guidelines suggest that the following patients are excluded from ventilator support and, depending on the scarcity of ventilators, are not candidates for intubation (see the “Ventilator Allocation Guidelines” for further details).

Exclusion criteria:

• Cardiac arrest
• Patients who, because of their expected prognosis, would not ordinarily meet criteria for ICU admission (e.g., advanced dementia or cancer)
• DNR or Do Not Intubate 
• Any condition expected to lead to short-term mortality 

Given enough time for information gathering, the New York guidelines also rely on the SOFA score, which assigns a color code of priority for ventilators (Figure 10.2): 

• Blue: exclusion criteria or SOFA score >11 — no ventilator or use alternative medical interventions or discharge to palliative care;
• Red: SOFA score <7 or single organ failure — highest priority for a ventilator; 
• Yellow: SOFA score 8 to 11 — intermediate priority; use ventilators as available; and 
• Green: no significant organ failure or does not need a ventilator — use alternative forms of intervention. 

For more information, refer to MDCALS’s SOFA score calculator.

Figure 10.2 Color-coded SOFA scoring system.

Patients are reassessed at 48 hours and periodically over time; the plan has additional information for decisions at these points in time. 

Other plans exist or are modified from the New York guidelines. It is essential that a plan be in place to assist the physicians who must make these difficult decisions in the emergency department and ICU.

Additional resources

1. Committee on Guidance for Establishing Crisis Standards of Care for Use in Disaster Situations; Institute of Medicine. Crisis Standards of Care: A Systems Framework for Catastrophic Disaster Response. Washington, DC: National Academies Press (US); 2012 Mar 21.
2. Colorado Department of Public Health. Colorado crisis standards of care.
3. Matos RI, Chung KK, Benjamin J, et al. DoD COVID-19 practice management guide: clinical management of COVID-19. Defense Health Agency. Published 2020 Mar 23.