Operational Steps to Implement a Triage System

Specific Actions Suggested Stakeholders Responsible
  1. Inventory of potential ICU resources for a surge in demand
    1. Physical ventilators and beds (eg, OR, PACU)
    2. Human resources (staff with ICU training)
    3. Supplies and space to deliver care (eg, medications, disposable items, PPE, PACU)
Individual health-care facilities
  1. Establish identification triggers for and initiation of triage: as clinical demand reaches crisis stage and that crisis standards of care, including triage, should be initiated
    1. The decision to initiate triage should be made by an identified regional authority with situational awareness of regional health-care demands
    2. Triage must be consistently applied across the region, with documented rationale and oversight by the relevant regional authority
Regional government health authorities (county/state/province/national)

Regional or national emergency management authorities (eg, CDC or equivalent, state/province public health department)
  1. Preparation of a triage system
    1. Create central triage committee for the region, tasked with coordination and standardization. This should include representation of key stakeholders (medical, nursing, ethics, law, patient and community representatives)
    2. Identify members of institutional tertiary triage teams and support structures
    3. Prepare and distribute training materials to local officials for standardization of implementation
Public health department/ministry of health

Local hospitals with an ICU
  1. Agreement on a triage protocol to target resources to those with the greatest incremental benefit
Regional health authorities and coalitions

Critical care professional societies and community, along with multistakeholder input

  1. Consideration of changes to allow limits to the delivery of life-sustaining measures in times of crisis care, and indemnity against litigation for decisions made in accordance with the triage policy
    1. Options include a modification or waivers of existing requirements through legislative means, an order through the Public Health Act, or through emergency powers
Regional health authority (ie, state health commissioner, provincial health minister)

Regional justice authority (ie, attorney general, governor)
  1. Standards of care
    1. Modify end-of-life care policies to indicate that the standard of care in a pandemic is to triage patients according to an accepted plan, and that consent is not required to implement treatment decisions taken according to that plan
    2. Ensure that patients unable to receive invasive life-sustaining therapies (eg, mechanical ventilation) are provided the best available care under the circumstances (eg, supplemental oxygen through another route, palliative care, family support)
    3. Clear clinical guidelines for medical management of people with respiratory failure, including palliative measures
    4. Standardized communication tools (eg, sensitive information sheets) to inform members of the public about triage decisions and the rationale behind them
State/provincial physician licensing board

Critical care/palliative care community
  1. Family and societal support
    1. Transparency with the public about triage processes
    2. Communication plans with the public (telephone hotlines, online resources) to ensure that information is readily available
    3. Work to preserve the integrity of family units, especially in cases of young children and during end-of-life
    4. Ensure support for grieving families
Institutional social work, mental health, and palliative care services

Consideration of COVID-19 hospice services
  1. Health-care worker support
    1. A systematic communication plan with the reasons for triage system activation, training on its use, and companion decision support tools to ensure consistent implementation is essential
    2. Triage decisions must be made collaboratively, using a team-based approach that includes the designated triage officer, providers directly assigned to care for individual patients, with support from hospital ethics and palliative care experts when necessary
    3. A systematic approach to support health-care workers, including incident debriefing, resiliency skills, and services to provide emotional support must be implemented in advance of triage system activation
Regional health authorities and attorney general, in collaboration with regional critical care leaders and ICU directors

Individual institutions
  1. Pediatric considerations
    1. Concentrate care for children at pediatric centers to preserve necessary pediatric systems, including accepting any pediatric transfers, even ones for whom they may not typically care
    2. Increasing pediatric age thresholds to 21, 25, or 30 years iteratively as surge requires (as long as no adult comorbidities exist that are not consistent with pediatric critical care practice)
Local health-care coalitions

Maves RC, Downar J, Dichter JR, Hick JL, Devereaux A, Geiling JA, Kissoon N, Hupert N, Niven AS, King MA, Rubinson LL, Hanfling D, Hodge JG Jr, Marshall MF, Fischkoff K, Evans LE, Tonelli MR, Wax RS, Seda G, Parrish JS, Truog RD, Sprung CL, Christian MD; ACCP Task Force for Mass Critical Care. Triage of Scarce Critical Care Resources in COVID-19 An Implementation Guide for Regional Allocation: An Expert Panel Report of the Task Force for Mass Critical Care and the American College of Chest Physicians. Chest. 2020 Jul;158(1):212-225. [PubMed Citation]