Ventilator Allocation Protocol

Ventilator Allocation Protocol  [pdf]

Ventilator Allocation Protocol  [docx]

Ventilator Allocation Protocol [google doc]

May be freely edited and used without attribution

Based on remarkable and comprehensive 2015 New York State Ventilator Allocation Guidelines

 

 

I’ve been getting a lot of questions. Below are points of clarification and explanation, most of this is just my opinion.

Yes you can use the protocol however you want, you do not need to ask me or provide any attribution. If you’re developing a protocol, you should read the original New York State 2015 guideline, there’s also a brief Hopkins paper, a Washington State guideline, a Henry Ford guideline created specifically for COVID19, and a CHEST consensus statement

Do everything feasible to not have to use an allocation protocol: reduce the burden of disease and increase capacity. Find vents in unusual locations (we’ve engaged our community where there are many thousands of unused vents from homebound ventilated patients who have died), 2 to 4 patients can share vents, look in every closet, decommissioned respiratory units, decommissioned hospitals. 

Goal is saving the most lives, in accordance with important societal values such as protecting vulnerable populations. You want to provide ventilator therapy to patients who are most likely to have their life saved by ventilator therapy, and remove ventilator therapy from patients who are unlikely to have their life saved by ventilatory therapy. In our minds we think about this problem as choosing among patients who will clearly die if they don’t get on a vent, but it’s important to remember that in this pandemic there has been a STRONG push to intubate early, that alternative forms of support don’t work and are more likely to aerosolize the virus so we should intubate early, and that is a big problem, from a scarce resources perspective because if ventilator therapy is a scarce resource, every patient who would fly off the vent that you intubate leads to another patient dying because they couldn’t get the vent they needed. Early reflection on the Italian response (by the Italians) suggests that they intubated too many patients too early and I’m concerned we’ll do the same. At the moment we are pushing HFNC under surgical mask, as the initial approach to COVID patients who need support; 30 lpm, FiO2 30%, titrate up until sat falls below 93% on maximal high flow support, then move forward with intubation. Is that the right approach? I don’t know. But last week, when we were in intubate early mode, we intubated 7 patients in one shift and that is clearly not sustainable.

You need vents, beds, and people trained to provide critical care. As a routine, in normal times we operate near capacity on all three, especially beds. There are of course other critical supplies in addition to ventilators, like PPE, oxygen. Per the NYS document, estimated 9000 ventilators in NYS, 10% suitable only for peds. Normal hospital utilization rate is 85%, so the vast majority of the 9000 vents are being used. The NYSTF calculated that in a severe influenza pandemic, about 19000 patients would require ventilators simultaneously, resulting in a shortfall of over 15,000 ventilators.

The ventilator triage committee must know the status of ventilators and critical care availability in the hospital moment to moment. We receive two reports per day. Patient’s attending provides clinical data to the triage committee, who determines that patient’s priority status based on the clinical data. Before the patient has been triaged, the committee should not be in contact with the patients, and in fact really they shouldn’t know the names of the patients being triaged. The triage committee should be identified well before they are needed, and the usual model would be that there is a single triage officer on duty at any given time, and that duty rotates among members of the committee. Since the triage decisions are entirely clinical, non-clinical members of the hospital staff or community don’t need to be on it, but how a hospital staffs its committee is a local decision.

Three steps: 1. Apply exclusion criteria 2. Assess mortality risk 3. For intubated patients, perform protocolized interval reassessments (48h, 120h, and every subsequent 48h). The original document stipulates that based on the observed characteristics of a particular pandemic, 48 and 120h may not be an appropriate interval, and the intervals should be adjusted based on what is observed for a specific syndrome, so for example if we find that COVID patients all have high SOFA scores for 10 days and then recover, we should push the intervals out, and if we find that all patients who are doing poorly at 72h end up succumbing to the disease, we should pull the intervals in.  Also if a patient develops an exclusion criterion at any point, such as a cardiac arrest or a change in goals of care, ventilator therapy should be removed at that point, you don’t wait for the next protocolized interval reassessment.

Age was rejected by the NYS task force as discriminatory – age of course indirectly contributes to exclusionary criteria and SOFA scores. The exception is children, based on strong societal preference. 17 and under are favored. The Hopkins protocol does use age or what they call life cycle considerations as a secondary criterion.

If you stipulate that being subject to the protocol is dependent on diagnosis, you will change diagnoses. Diagnoses often aren’t clear. Although all patients needing a ventilator are subject to the allocation protocol, I think an exception should be made for patients who are thought to require intubation temporarily for unrelated reasons, e.g. someone who has perforated diverticulitis may need to be intubated for the surgery, but should probably be exempted from the protocol.

SOFA is used as a proxy for mortality risk. Some experts disagree with this, suggesting that SOFA performs poorly as a mortality predictor in primary lung disease. SOFA score has limitations – does not predict mortality nearly as well in ILI compared to sepsis. GCS component difficult to evaluate in intubated/sedated patients, uses outdated hypotension criteria (dopamine, dobutamine). Much better would be a disease-specific predictor of short-term mortality, which, for COVID, we may soon have.

You want to start classifying patients as blue red yellow green somewhat before you run out of ventilators–you don’t have to act on exclusion criteria until you run out, but if you start early, you will know exactly who is removed from ventilator therapy when you do run out. If you wait until you actually run out, it’ll be a mess. And what that means is that you have to stratify every patient in the hospital on a vent as blue red yellow green, which in many centers will take a while, before you run out. 

Should family members be allowed to bag indefinitely? It’s an interesting question, the NYS task force“discouraged it” and I do too, because I think it places a burden on the family that most would prefer to not have, though that’s very paternalistic. Also, it places a burden on the facility, compromising the care of others. Who takes over when the family has to pee? Or when they pass out? Should we allow teams of family members to be at bedside, bagging, exposing them to all the sick patients on the ward, potentially making patients out of them? These family members will contract the illness and transmit it. But I can see counter-arguments. See page 70 of the source document.

Regional command centers seem crucial, so that resources like beds and ventilators can be shifted from places of surplus to places of shortage, and patients can be transferred to facilities that have capacity. 

Withholding or withdrawing a life-sustaining therapy without the consent of patient or proxy is a profound, devastating decision that will severely affect some healthcare workers, and these consequences, along with the possible legal ramifications of these decisions, are partly why it is essential that they are undertaken according to an established protocol, ideally a protocol that is as objective as feasible. NEJM perspective piece suggests you can’t withdraw care; they suggest that withdrawing care has been determined to be illegal and will harm healthcare workers, and both of those things are true but I don’t see how that absolves us of our mandate to ethically allocate resources during a disaster. Disallowing withdrawal of ventilator therapy installs a first come first served system that is in my view profoundly unethical, it’s not hard to imagine huge numbers of patients on vents for weeks or months who have little to no chance of recovery.

Should healthcare workers receive priority? There is a whole section on this and the task force decided no, and I agree. It is our duty to run into the fire, that’s what we signed up for. Once a healthcare worker needs a vent, she’s not returning to care for others in a pandemic, so the argument that we get priority so we can continue to care for patients is moot. Many others put themselves in harm’s way during a pandemic, where do you draw the line? Do all technicians, janitorial staff qualify? What about a home health aid taking care of someone affected at home? There are actually so many healthcare workers in the community that in a shortage, only healthcare workers would get vents. Also, the notion that we are more valuable to the community, even in a pandemic, is probably bunk. If all the doctors disappeared during this pandemic, there would be a lot of needless deaths, but it would be a lot worse if all the police officers, or all the sanitation workers disappeared. Also it seems particularly self-serving to prioritize healthcare workers in a policy designed primarily by healthcare workers, and such a feature of the policy would erode public trust in the policy and in healthcare workers more generally. Emanuel et al take the opposite view in their NEJM essay

There are all sorts of special categories of people that seem to have justification for being favored or disfavored in a policy: the elderly, pregnant patients, parents, prisoners, undocumented immigrants, community leaders, there’s no end to it and I agree with the task force that a triage system based on clinical features alone is the most sound.

The New York State guideline did not use functional status as an exclusion criterion to avoid judgments around quality of life. I am comfortable with such judgments though, especially when they include an objective criterion, which is why I included the ECOG scale criterion (I used ECOG score of 4, some might say it should be 3). However, these criterial (e.g. metastatic cancer, which I suggest as a criterion for poor prognosis and exclusion), are open to challenge. There are more explicit criteria listed in the Hopkins document, under Table 1.  You may not know if a patient has very poor functional status at the outset of care, but it’s reasonable in my opinion to assume it if the patient has, for example, bedsores.

If a patient is intubated prior to the discovery of an exclusion criterion, ventilator therapy should be removed as soon as an exclusion criterion is known. It is reasonable to intubate DNR patients in a non-shortage, but not, in my opinion, in a shortage, though this stipulation is also open to challenge and diverges with the NYS guideline.

SOFA < 7 OR single organ failure in the initial triage is odd. My read on it you are allowed to classify a patient as red even if they have a high SOFA if it is clear that they have only a single organ system down, which would be a sort of failure of the SOFA score; i.e. if you have a only one system down you should not have a high SOFA, but if you for some reason do have a high SOFA with one system down, you can still be red.

Comparing patients within class evokes a “war of all against all,” one of the key features of the system is that within a class, triage is made by randomization (i.e. a lottery). I think this is a very strong feature of the system. Trying to further clinically differentiate among red patients using an objective system I think would be very difficult and open to interpretation/exploitation/gaming. First come first served favors the rich/educated/empowered.

When the need for a vent is identified, are there vents available right now? If no, classify patient. If red, that patient is added to the pool of reds and as soon as a vent becomes available (because a red vented patient has been reclassified or died) all reds are randomized to that vent.

Keeping the public informed on the possible need for removal of ventilation, and ongoing data collection, are essential. Relatives must be informed that all ventilator therapy during a shortage is a trial of therapy that may be discontinued if it does not result in clinical improvement at a pre-specified pace. Seattle Tough Conversations Document.

Hopkins group suggests the triage officer (with other administrators in tow) tell the family about allocation decisions. I think it should be both–triage officer, attending, and possibly others (high ranking hospital official such as the CMO or CNO, pastoral care, ethics committee liaison). 

If a chronically vented patient comes in with their own ventilator it seems appropriate to me to exclude them from the protocol.

ED must know when no vents are available, so that ETI is avoided. If a patient comes in intubated (without their own ventilator) and there are no vents available, and all vented patients are red priority, the newly intubated patient should be extubated. If there is a lower priority patient (i.e. a blue/yellow patient already intubated), that patient should be extubated while the new patient is bagged. If uncertain at any given moment, err on the side of ETI and bagging, until the situation can be more comprehensively assessed. Extubating is logistically/emotionally harder but ethically identical to not intubating.

Airborne Isolation / COVID19 Intubation Checklist

AIIC [pdf]

AIIC [image]

more pearls: make sure cuff is inflated prior to manual ventilation. attach viral filter directly to ETT, if circuit disconnection needed, disconnect circuit on vent side of filter.

References: Zuo 2020, Wax 2020, Weingart 2020, ecuus 1 and 2, Farkas & Thomas 2020

CDC 5 min video on proper donning/doffing, pdf, pulmcrit cheat sheet

 

CDC CV19 Discharge Instructions

LAC DOH CV19 Discharge Instructions

 

Scott’s BVM-on-NIV mask oxygenation setup (6 min vid)

 

How To Present to an EM Attending

The major challenge as a trainee presenting to a supervising attending is that every attending is different, wants different things, has a different approach, which makes your job impossible. You will do better to have a system. Here’s one system.

Before presenting the case at hand,  provide an update on what’s going on with your other patients. How are they doing? What are they waiting on? Now you’re ready to start in with the present case.

Frame First. Open up with a very brief one-sentence summary of the case, with your conclusion. This frames everything else you’re about to say.

“I think Ms. Jones has pneumonia.”

“I think Mr. Smith will need a CT scan for rule out appendicitis.”

“I think Mr. Lee will need a workup for chest pain, but if negative can be managed as an outpatient.”

Next is the chief complaint.

“Mr. Jones is a 34 year old male with abdominal pain.”

Past medical history follows, most important first. 

“He had a kidney transplant in 2004 for polycystic kidney disease. He is also known for diabetes and hypertension.” 

Notable medications, especially important are recent changes in medications or noncompliance, and relevant allergies to medications.

“He’s on cyclosporin and mycophenolate, as well as glyburide, amlodipine, and hydrochlorothiazide. His amlodipine dose was recently doubled. He reports a penicillin allergy, which gives him a rash.”

Pertinent social situation follows, as it pertains to the situation. This is often omitted, but social situation plays an important role in admit/discharge decisions;  how can you discharge a patient without knowing the environment you are discharging to?

Who does the patient live with? (alone / with family / with spouse, who also has advanced dementia)

What sort of living environment does the patient reside in? (apartment / group home / nursing home / homeless)

What does the patient do during the day? (works as an administrator / is a left-handed pianist / is unemployed / is a student)

What is the patient’s level of function? (fully functional / able to do some but not all ADLs / fully dependent) 

How much help does the patient have at home? (24/7 home health aide / home health aide twice per week for 6 hours / visiting nursing every day)

Bad habits? (drugs, alcohol, cigarettes. history of withdrawal)

Does he have physicians looking after him? If the patient was referred to the ED by a physician, this is particularly important. If there are clinicians who play a particularly relevant role in the present concern, report this. Taking care of patients is a team sport.

Does the patient have any advanced directives? What are the goals of care?

“He lives with wife, works as a bus driver. Denies bad habits. Is supposed to follow with Dr. Green in the renal transplant service at Heartbreak Hospital, but hasn’t seen Dr. Green in six months.” 

Next is a good place to comment on prior visits to the ED.

“He’s never been to this department.”

“He has 48 similar visits to this department, has been extensively worked up dozens of times.”

Next is the history of present illness. This should start with “[The patient] was in his usual state of health until…” and then provide a chronological sequence of events that led up to the present visit; the first part of the HPI should report all the patients complaints, which were elicited with open ended questions, and end with the complaints that led to his coming to the ED, and then what complaints he has at this moment. The next part of the HPI is the focused review of systems, which you can delineate from what the patient offers up without prompting by using phrases like, ‘on questioning,” ‘endorses,’ and ‘denies.’ This is not a complete review of systems, but a focused review of systems with pertinent positives followed by pertinent negatives. A good way to end the HPI is to comment on prior episodes.

“Mr. Jones was in his usual state of health until 3 days ago, when he developed dull periumbilical pain that was intermittent but progressive until this morning, when he developed vomiting and the pain became constant, sharper, and moved to the right lower quadrant. He went to see his family physician, who referred him to the emergency department. At the moment he complains of severe right lower quadrant pain and nausea. On questioning, he endorses diarrhea and chills, but denies mucus or blood in the stool, recent travel or antibiotics, urinary or testicular complaints, shortness of breath, and rash. He had a similar, much less severe episode a few months ago that resolved in one day by itself.”

After the HPI comes the physical exam, which should always start with general appearance and vital signs, and then proceed from head to toe, with a level of detail appropriate for your level of training. I think it is best to leave the area of interest for last. 

“Mr Jones is well appearing, calm, and mildly uncomfortable in abdominal pain. His vitals are normal except for a heart rate of 106. His head to toe exam demonstrates no findings about the head, neck, heart, lungs, and extremities. His abdomen is moderately tender in the right lower quadrant, without signs of peritonitis. His GU exam is normal.”

Now you’ve finished the H&P, and the next question is what has been done for the patient already, if anything, and results

“He was treated with 4 mg of IV morphine and 4 mg of IV ondansetron, and a CBC, chemistry, LFTs and lipase were sent, as well as a urine analysis, according to the abdominal pain nursing protocol. He was uncomfortable when I saw him, so I ordered another 4 mg of IV morphine. The UA has been resulted and shows trace blood, all other studies are pending.”

And now your assessment and plan. I think the best way to provide a summary of the key features of the case, and then answer these questions:

  1. What do you think the patient has?
  2. What dangerous conditions or complications could be causing or associated with this patient’s symptoms?
  3. What tests are indicated to rule out or rule in these dangerous conditions?
  4. What therapies or symptom relief measures are needed?
  5. If the tests that you order are negative, what is the plan for the patient?

“Mr. Jones is a healthy young man with abdominal pain, diarrhea, and fever for 36 hours, his exam is reassuring but he has mild lower abdominal tenderness. Most likely, Mr. Jones has a self-limited GI illness, but I’m concerned about appendicitis. Bowel obstruction and perforated ulcer are unlikely given the relatively benign abdomen. Given a normal GU exam, I don’t think we need to further pursue a lesion there; his abdominal tenderness makes thoracic causes of abdominal pain like pneumonia or cardiac etiologies very unlikely. If his labs show no diagnostic abnormalities, I think he needs a CT scan of the abdomen with IV contrast to rule out appendicitis. If that’s negative, I think he’s safe to be discharged with a nonspecific diagnosis and followup. He’s comfortable right now but I’ll continue to treat for symptoms as needed, and I’ll also give him a liter of fluid.”

The most important way that this system differs from the most common presenting style is that the HPI is presented after the patient’s background information is presented. Most attendings will want to hear the HPI first; I believe that in a stable patient, the HPI can only be properly interpreted in the larger context of the patient’s medical history, social history, etc.

How much detail you present depends on the complexity of the case and how senior you are as a trainee. If you’re about to graduate your residency, your attending may not want to hear anything else than, “Mr. Jones is a healthy 34 year old with a flu-like syndrome, I discharged him with follow up.”

Send thoughts, comments, suggestions, objections, additions to emupdates@gmail.com

 

Related:

Trainee worksheet, with specific guidance on how to succeed during an EM shift. Designed to fit on one page, front and back.

List of ways that I might practice differently than other attendings, to save residents some trouble.

Older, detailed guide to patient assessment.

Update: 1. facts 2. opinions 3. questions

The Abortion Pill

Pregnancy termination is now very difficult to get in many regions. The abortion pill–medication abortion–is one dose of the antiprogesterone mifepristone followed by one or more doses of the prostaglandin misoprostol. The therapy is well studied and unequivocally safe and effective up to 10 weeks gestation.

For women who have access to both medication and surgical abortion, there are plusses and minuses to each but the main difference is that a surgical abortion is a brief procedure requiring anesthesia and uterine instrumentation, whereas a medication abortion occurs over several days in the patient’s home.

But medication abortion allows women without access to surgical abortion to  safely terminate pregnancy. In the US, federally authorized abortion pills are highly restricted for reasons that are political, not medical. So a network of activists have developed robust programs for getting this treatment into the hands of women who need it.

The role of emergency providers in managing women who request elective termination of pregnancy depends on the resources available in your community, but all of us need to know about medication abortion, if for no other reason than it is a rising therapy and you’re going to get asked. Especially if you practice in an area where surgical abortion is poorly available or unavailable, familiarize yourself with the relevant options so you can properly counsel appropriate patients. This is another way that emergency clinicians stretch the scope of their practice to meet the changing needs of the patients they serve.

Plan C

Aid Access

New York Times, Farhad Manjoo

Narcotica podcast

Ketamine-Only Breathing Intubation

This 9 minute video demonstrates the strengths and weaknesses of an intubation strategy that relies on dissociation with ketamine.

The essential strength, compared to RSI, is that a breathing technique keeps the patient breathing during laryngoscopy, which transforms the procedure from high-adrenaline to highly controlled. You see in this video that my (fabulous) resident was able to take his time, try different blades, slowly advance and adjust while using view optimization techniques as the patient continued to breathe. This is an extremely powerful way to add safety to the riskiest procedure commonly performed in acute care. We would have been able to carry on with his attempts for longer, had we not been inconvenienced by the arrival of a trauma patient.

Keeping the patient breathing during intubation has a long history in emergency medicine, starting with the brutal and often unsuccessful blind nasal intubation, which, fortunately, is now seldom performed. Many of us learned to do operating room style awake intubation, which relies on thorough local anesthesia using atomized/nebulized/topicalized/regionalized lidocaine, so the patient can remain truly awake and breathing during the procedure. Lidocaine-focused awake intubation is a fabulous technique that requires expertise and equipment not available to all acute care providers, but also–depending on your level of skill–time and patient cooperation. Time and cooperation is something we may not have downstairs or on the side of the road,* but what we lack in time and cooperation, we can make up for in ketamine.

When we use dissociative-dose ketamine to do the heavy lifting in allowing the patient to tolerate laryngoscopy, we obviate much of the needed topicalization expertise/supplies, abbreviate the needed time, and add cooperation with ketamine, cooperation in a vial.  The patient becomes dissociated, breathing but unconscious, which is why I use the term breathing intubation rather than the much more accepted term awake intubation to describe it.

Many patients who receive dissociative-dose ketamine without a paralytic will have some muscle rigidity, and some will develop laryngospasm (which is glottic muscle rigidity).  The patient in this video had some rigidity, which resolved and was not a problem, and this is usually the case. But patients who get ketamine to facilitate laryngoscopy are at much higher risk than procedural sedation patients (who are not having their airway instrumented) to develop laryngospasm and occasionally jaw rigidity, which, together, can cause an immediately dangerous cannot intubate cannot ventilate scenario. Anytime KOBI is being undertaken, a paralytic must be immediately available, ideally drawn up in a syringe, so that the procedure can be converted to a paralyzed technique at any point.

How KOBI fits into our expanding airway toolkit is expertly described by Andrew Merelman and Michael Perlmutter in this WJEM paper.

 

 

 

*some airway experts disagree

 

Postoperative Neck Hematoma

Postoperative neck hematoma is not often discussed in emergency medicine but behaves a lot like neck trauma, because it is neck trauma. These patients should be managed with a high-resource approach and discharged reluctantly, after careful deliberation.

Adapted from Bittner, MD.

ED Chest Pain Evaluation Pathway

full pathway as png and pdf

This pathway was agreed upon by a hospital consortium; it is completely unsubstantiated by science and is only intended to serve as a supplement to your otherwise excellent clinical judgment.

Strengths: it reminds you to consider the 7 dangerous causes of chest pain, not just ACS. It’s pretty straightforward and based on well-validated decision tools.*

Weaknesses: chest pain is a complex problem that cannot be reduced to a pathway, even a pathway designed by smart, good-looking people. Don’t turn your brain off when using this or any other decision tool. Decision tools don’t take care of patients, you do.

credits: bradley shy, marc probst, nick genes and the HIC consortium.

 

*except the ADD score, which is not well validated and remains controversial. Nobody knows who needs a scan for dissection. Make sure you scan the patients who have very suggestive presentations, even though the vast majority of them will not have dissection. Think about dissection when patients have features in the score. Understand that you will eventually miss dissection because sometimes it presents in crazy atypical ways, and that if you try to catch very atypical dissections you will do more harm than good by overuse of CT.

Low Threshold Buprenorphine

 

Sustained comprehensive addiction care is the goal, but until then, most OUD patients should get buprenorphine in the ED and/or a script. Every hour a street opioid user is therapeutic on bup is an hour they’re safe from withdrawal, cravings, and overdose, and is an hour they can contemplate recovery.

The Paper Throat: A Lo-fi, DIY Laryngoscopy Simulator

 

Laryngoscopy involves a series of unnatural movements and hand-eye skills that are not easily learned while simultaneously caring for a dying patient. The Paper Throat is a low fidelity but high yield direct laryngoscopy training tool that is easily assembled and practiced. The hope is that routine use will generate laryngoscopy muscle memory so that training providers can focus on other aspects of airway management when called upon to intubate IRL.

Conceived and produced by Jonas Pologe.

Pulse Ox Lag

Folks put a lot of stock in the pulse oximeter, as they should, because the pulse ox is an awesome feat of engineering and patient safety. But the pulse ox lags.

Here, the inestimable Dr. Jonas Pologe (rhymes with apology) demonstrates pulse ox lag with a breath hold.

Breath hold starts at 0:11, sat is 100%
Saturation starts to drop at 0:48
Breathing commences at 1:25, sat is 82% at this point
Saturation continues to drop until 1:46, then recovers from its nadir of 77%
At 1:58, saturation reaches 100% again

 

Lessons:

1. When the sat is on its way down, the patient is more hypoxic than the pulse ox shows. This is another reason why, when laryngoscopy is not producing an acceptable view of the glottis, you should come out and reestablish ventilation/oxygenation earlier than you think. A more important reason to come out and bag early is described here.

2. When you are reestablishing oxygenation (using a bag mask, laryngeal mask, or endotracheal tube), do not use the pulse ox to judge the adequacy of ventilation, use capnography. That means the capnogram should be attached to the bag mask/LMA/ETT before the first breath is given. If the capnogram is good, ventilation is good, and the pulse ox will catch up, so relax and stop bagging so quickly.