[KSCCM-COVID19] 관련논문 1

  • 작성자

    KSCCM
  • 작성일자

    2021-01-05 00:00
  • 조회수

    209

 

Managing intensive care admissions when there are not enough beds during the COVID-19 pandemic: a systematic review

 

                                                              Tyrrell CSB, et al. Thorax. 2020.

 

COVID-19 3차 유행으로 중환자들이 급격히 늘면서, 제한된 인력과 중환자 병상으로 인해, 중환자실 입실 기준 (triage decision) 에 대한 많은 고민들이 있습니다. 본 저널은 COVID-19 대유행 시기 동안 제한된 의료자원을 가지고, 누구에게 기계환기 같은 potentially life-saving treatment을 적용해야 할 지 결정해야 하는 의료진을 도와주기 위해 여러 나라들에서 발표한 중환자 입실기준에 대한 가이드라인들의 체계적 문헌고찰을 통해, 일선에서 근무하는 의료진들에게 방향성을 제시하고자 하였습니다.

 

쳬계적 문헌고찰에 포함된 7개의 가이드라인들을 9가지 항목으로 분류하여 표1에 정리하였습니다.
 

 

<표1>

 

 

 

Toolkit for COVID-19Kansas Department for

Health and Environment

(Kansas, USA)

Clinical ethics

recommendations

for the allocation

of intensive care

treatments in

exceptional resource-limited

circumstances

Italian Society of

Anaesthesia, Analgesia

and Intensive Care

(SIAARTI)

The Australian and

New Zealand Intensive Care Society COVID-19

Guidelines v1

Ethical principles

concerning

proportionality of

critical care during the COVID-19 pandemic: advice by the Belgian

Society of Intensive Care Medicine

Department of Defense

COVID-19 practice

management guide

(US military hospitals)

COVID-19 pandemic:

triage for intensive

care treatment under

resource scarcitySwiss Academy of Medical Sciences

COVID-19 rapid

guideline: critical care in adultsNational Institute for Health and Care Excellence (NICE)

(UK)

1. Development of guideline process

By expert panel

By expert panel

Consensus-based

By expert panel

By expert panel

Based on previous

pandemic guidelines.

Adapted by experts

Evidence review and rapid consultation

2. Ethical Framework: distributive justice

« triage criteria for allocating resource  

Emphasizes maximising lives saved.

For patients of similar risk-benefit

category, allocation should be at random or first come, first served.

Maximize benefits for the greatest number of people.

Discusses possible need of using first come, first served during resource saturation.

Emphasizes

maximising lives saved.

Emphasizes

maximising lives saved.

 

Maximising lives saved is a decisive factor for purposes of triage.

Acknowledges

importance of equity

and protecting healthcare professionals.

 

3. Criteria for admission

Primarily medical

survivability determined by clinical judgement or formal means (eg, SOFA score).

Exclusion criteria for

severe conditions (eg, metastatic disease with poor prognosis, end-stage organ failure).

Age (with possible

upper limit);

comorbidities;

functional status.

Probable outcome

of the patients

condition; burden

of ICU treatment;

comorbidities;

likelihood of response to treatment.

Probable outcome of patients condition; frailty in elderly patients (eg, Clinical Frailty Score); cognitive

impairment in elderly patients; comorbidities

(particularly severe or life-limiting

conditions);

age alone should not be used

Each hospital should provide a specific plan regarding ICU

admission/exclusion

criteria.

Age and comorbidities

should be a factor

for provision of (any

form of) care for older patients.

Patients who are most

likely to survive to

discharge.

Specific exclusion

criteria given, primarily related to severe life-limiting underlying conditions; when no ICU beds available, a broader set of conditions and any patient aged >85

years, regardless of

underlying health.

Based on likelihood

of recovery. Frailty

(using Clinical Frailty Score or individualised

assessment of frailty if score not appropriate);

comorbidities; patient wishes.

4. Criteria adapt as demand changes

Yes. Hospitals should adapt based on resources.

Yes. Criteria need to

be flexible based on

resource availability.

Yes, living document will be continually revised.

 

Yes. Different criteria for different levels of capacity

Two sets of criteria

: (A) capacity limited, (B) no beds available.

 

5. Criteria for discharge

Yes. Reassess every 48 hours, with step down if exclusion criteria are met.

No explicit criteria,

de-escalation decisions should not be postponed.

 

 

 

Yes. Reassess every

48 hours with specific

clinical discontinuation

criteria given

No explicit criteria but stop when not achieving outcomes

6. Equality

between COVID-19 and other health conditions

 

Yes

Yes

Yes

 

Yes

Yes

Elective procedure and non-urgent hospital care ¯

7. Equality across healthcare system

Ventilated patients in chronic care facilities would not

be subjected to acute care triage guidelines.

Uniform policies are

required to avoid

inequalities

Partiallyprinciples

established but

anticipate different

thresholds locally based on local capacity and demand.

While similar

criteria should apply

across all jurisdictions,

the ultimate decision-making

is at discretion

of senior intensive care medical staff.

Each hospital drafts

their own ethical

guideline

Each hospital

should have their own criteria and implement based on their own

resources

Yes. Uniform criteria

across the country

Hospitals should discuss sharing of

resources and transfer patients between units in other hospitals to ensure best use of critical care

8. Decision-making processes and support

Triage team (medically led and independent of treating doctor) will

make decisions on

resource allocation for individual patients, and its decision-making

scrutinised by a review committee.

Decision-making

responsibility is for

doctors managing

caresuggests second opinion for challenging cases.

Treating clinician

responsible for decision-making.

Shared decision-making with other clinicians

Decision to deny or

prioritise treatment

made by two or three doctors in consultation.

Psychological support offered to clinicians making triage decisions.

Keep register of all

triage decisions

 

Decisions to be made by multidisciplinary team, which may include input from ethicists.

Most senior clinician takes responsibility. Deviation from guidance possible

but must be clearly

stated why

Decision-making is by the critical care team.

9. Communication of decision

 

Yes. Communicate

decisions with patients and obtain their wishes.

Yes. Shared and

transparent decision-making process with

patients and relatives

Yes. Open

communication with

patient and family

Providers should avoid discussing rationing of

care at the bedside

Discussed but must be

transparent.

Open communication with patient and family and shared decision-making

 

ECMO 적용 결정은, ELSO guideline에서는 경미한 병증을 지닌 젊은 환자나 의료종사자에 우선 순위를 적용하고, 중증이거나 7일 이상 기계환기를 시행한 환자는 제외 기준에 넣었다. 21일 이상 심폐기능의 호전이 없으면 de-escalation 을 권유하였다

 

요약하자면 대부분의 가이드라인에서 ‘triage’ 의 중요성을 언급하였고, 제한된 의료자원의 배분을 위해 윤리적 측면을 고려하여 입실과 퇴실 기준 의 중요성을 기술하였다. 또한 가이드라인은 의료체계 전반적으로 공정하고 동일하게 적용될 수 있는 원칙을 포함해야 한다.

 

증거 기반 지침 (evidence-based guidelines)의 수립은 의료 현장에서 일관성 있는 치료를 유지하고 어려운 의사 결정 시 임상의들의 부담을 경감시키고. 환자의 예후를 향상시킬 수 있다. 

 

 

* 위 내용과 동일한 첨부파일도 함께 첨부하오니, 참고 부타드립니다. 

첨부파일


TOP