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State of the art review
Managing intensive care admissions when there are not enough beds during the COVID-19 pandemic: a systematic review
  1. Carina S B Tyrrell1,
  2. Oliver T Mytton1,2,
  3. Sarah V Gentry2,3,
  4. Molly Thomas-Meyer2,
  5. John Lee Y Allen4,5,
  6. Antony A Narula5,
  7. Brendan McGrath5,6,
  8. Martin Lupton7,
  9. Jo Broadbent2,
  10. Aliko Ahmed1,2,
  11. Angelique Mavrodaris2,8,
  12. Anees Ahmed Abdul Pari2,9
  1. 1 MRC Epidemiology Unit, University of Cambridge, Cambridge, UK
  2. 2 Public Health England, East of England, Cambridge, UK
  3. 3 Norwich Medical School, University of East Anglia, Norwich, UK
  4. 4 Oxford University Hospitals, University of Oxford, Oxford, UK
  5. 5 Global Tracheostomy Collaborative, Boston, Massachusetts, USA
  6. 6 Manchester Academic Critical Care Research Group (MACC), The University of Manchester, Manchester, UK
  7. 7 Faculty of Medicine, Imperial College London, London, UK
  8. 8 Institute of Public Health, University of Cambridge, Cambridge, UK
  9. 9 Cambridge Judge Business School, University of Cambridge, Cambridge, UK
  1. Correspondence to Dr Carina S B Tyrrell, MRC Epidemiology Unit, University of Cambridge, Cambridge CB2 0SL, UK; carina.tyrrell{at}mrc-epid.cam.ac.uk

Abstract

The surge in cases of severe COVID-19 has resulted in clinicians triaging intensive care unit (ICU) admissions in places where demand has exceeded capacity. In order to assist difficult triage decisions, clinicians require clear guidelines on how to prioritise patients. Existing guidelines show significant variability in their development, interpretation, implementation and an urgent need for a robust synthesis of published guidance. To understand how to manage which patients are admitted to ICU, and receive mechanical ventilatory support, during periods of high demand during the COVID-19 pandemic, a systematic review was performed. Databases of indexed literature (Medline, Embase, Web of Science, and Global Health) and grey literature (Google.com and MedRxiv), published from 1 January until 2 April 2020, were searched. Search terms included synonyms of COVID-19, ICU, ventilation, and triage. Only formal written guidelines were included. There were no exclusion criteria based on geographical location or publication language. Quality appraisal of the guidelines was performed using the Appraisal of Guidelines for Research and Evaluation Instrument II (AGREE II) and the Appraisal of Guidelines for Research and Evaluation Instrument Recommendation EXcellence (AGREE REX) appraisal tools, and key themes related to triage were extracted using narrative synthesis. Of 1902 unique records identified, nine relevant guidelines were included. Six guidelines were national or transnational level guidance (UK, Switzerland, Belgium, Australia and New Zealand, Italy, and Sri Lanka), with one state level (Kansas, USA), one international (Extracorporeal Life Support Organization) and one specific to military hospitals (Department of Defense, USA). The guidelines covered several broad themes: use of ethical frameworks, criteria for ICU admission and discharge, adaptation of criteria as demand changes, equality across health conditions and healthcare systems, decision-making processes, communication of decisions, and guideline development processes. We have synthesised the current guidelines and identified the different approaches taken globally to manage the triage of intensive care resources during the COVID-19 pandemic. There is limited consensus on how to allocate the finite resource of ICU beds and ventilators, and a lack of high-quality evidence and guidelines on resource allocation during the pandemic. We have developed a set of factors to consider when developing guidelines for managing intensive care admissions, and outlined implications for clinical leads and local implementation.

  • assisted ventilation
  • critical care
  • respiratory infection
  • viral infection
  • ARDS
http://creativecommons.org/licenses/by-nc/4.0/

This is an open access article distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited, appropriate credit is given, any changes made indicated, and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/.

https://doi.org/10.1136/thoraxjnl-2020-215518

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    Footnotes

    • Twitter @Carina_Tyrrell

    • Contributors The first and last authors are the guarantors of the study. Contributor role: CSBT: conceptualisation, formal analysis, investigation, methodology, project administration, writing A and writing B. OTM, SVG, JLYA: conceptualisation, formal analysis, investigation, methodology, writing A and writing B. MTM: conceptualisation, methodology, writing A and writing B. AAN, BMG, ML: conceptualisation, methodology and writing B. JB, AA: conceptualisation, supervision and writing B. AM: conceptualisation, methodology, supervision and writing B. AAAP: research question formulation, conceptualisation, methodology, project administration, supervision and writing B. Role definition: Conceptualisation: ideas; formulation or evolution of overarching research goals and aims. Data curation: management activities to annotate (produce metadata), scrub data and maintain research data (including software code, where it is necessary for interpreting the data itself) for initial use and later reuse. Formal analysis: application of statistical, mathematical, computational or other formal techniques to analyse or synthesise study data. Funding acquisition: acquisition of the financial support for the project leading to this publication. Investigation: conducting a research and investigation process, specifically performing the experiments, or data/evidence collection. Methodology: development or design of methodology; creation of models. Project administration: management and coordination responsibility for the research activity planning and execution. Resources: provision of study materials, reagents, materials, patients, laboratory samples, animals, instrumentation, computing resources or other analysis tools. Software: programming, software development; designing computer programs; implementation of the computer code and supporting algorithms; testing of existing code components. Supervision: oversight and leadership responsibility for the research activity planning and execution, including mentorship external to the core team. Validation: verification, whether as a part of the activity or separate, of the overall replication/reproducibility of results/experiments and other research outputs. Visualisation: preparation, creation and/or presentation of the published work, specifically visualisation/data presentation. Writing A–original draft preparation: creation and/or presentation of the published work, specifically writing the initial draft (including substantive translation). Writing B–review and editing: preparation, creation and/or presentation of the published work by those from the original research group, specifically critical review, commentary or revision–including prepublication or postpublication stages.

    • Funding The lead author is a National Institute for Health Research (NIHR) Academic Clinical Fellow (Postidentifier is ACF-2018-14-504).

    • Disclaimer The NIHR had no role in the study design, the writing of the paper, nor the decision to submit the paper for publication.

    • Competing interests None declared.

    • Patient consent for publication Not required.

    • Provenance and peer review Not commissioned; externally peer reviewed.