Triage: When beds are full, who gets treated?

At the 127th DGIM Congress, Prof. Christian Schulze (Friedrich Schiller University, Germany) presented "Models of Triage in High Patient Influx."

Amid the pandemic, there have been great successes

At the 127th Congress of the German Society of Internal Medicine, Prof. Christian Schulze (Friedrich Schiller University, Jena, Germany) presented "Models of Triage in High Patient Influx."

The experienced cardiologist began his talk by noting that the COVID-19 pandemic is not only a major challenge, but also a validation of modern medicine. "We can share information in a very short period of time in a way that would not have been possible fifty years ago. And there have been great successes in fighting the pandemic together."

As head of a university cardiology department, he said, he was particularly interested in the fact that COVID-19 infections were seen very early on not only as lung infections, but also affecting peripheral organs, including the cardiovascular system, through generalized mechanisms of infection.

After these introductory statements, the speaker moved on to the much-discussed topic of triage. "It is ultimately nothing more than the assessment of the urgency of treatment within a few minutes based on vital signs and symptoms," the cardiologist said. A distinction must be made between "hard triage" and "soft triage." The former "is actually only known from wartime." Here, care mechanisms are only possible if patients are categorized accordingly. “Soft triage" on the other hand, has currently been practiced for a year. It allows suboptimal care by transferring or postponing. Especially in the cardiovascular field, many elective procedures have been cancelled.

What are the triage criteria?

According to the established Manchester Triage System (MTS), the following categories are relevant in the initial assessment:

Then, the waiting time until treatment is categorized. The following factors are not relevant:

This is contrasted with the Emergency Severity Index (ESI), which is the same system with some modifications. The need for treatment is classified according to whether the patients are high-risk and how many resources are required for their treatment. There is also the estimation of prognostic factors, vital parameters.

"The system is at a breaking point"

The speaker went on to look at the current situation: at the time of the session, there are 4,679 patients in ICUs across Germany. 88% of the country’s approximately 21,000 beds are occupied, and about 3,000 beds are vacant for conditions requiring intensive care. The system is at its limit, Prof. Schulze summed up. This is one reason to look at the experiences from triage during the Bergamo COVID-19 wave in March 2020. There, clinical factors and age were used in triage. The principle was not to save a particularly large number of people, but to save as many life-years as possible. In Germany, this was implemented differently in line with the Basic Law, the German version of a national constitution. "We pursue prioritizations not with the intention of valuing human lives, but in such a way that limited resources benefit as many patients as possible." It is essentially a matter of treatment according to the likelihood of success. If the chances of survival are low, intensive care is not provided.

A position paper by the German Association of Scientific Medical Societies (in German: Arbeitsgemeinschaft der Wissenschaftlichen Medizinischen Fachgesellschaften or AWMF) put all this in pragmatic terms. According to this, factors for a decision include the severity of the overall disease. COVID-19 is not emphasized separately.

Patients are evaluated by the triage team using a multiple-eye principle. Consent is obtained from patients or their representatives. And then treatment priority is determined. Comorbidities are often difficult to assess. And this is where sometimes a gray area may emerge. "It may well be that the patient with obesity and severe kidney disease, and also with heart failure, has a better prognosis than a patient who has no comorbidities." Hence, continued re-evaluation will be determined.

Impact on cardiovascular patients

Early data from the city of Homburg (Saarland, Germany) showed a nearly 70% reduction in cardiovascular patients immediately after the initial shutdown. Emergency department visits declined. But the interaction of emergency physicians in the prehospital setting, the emergency departments, and the service-providing hospitals continued to work very well.

The rule is: from symptom onset to revascularization, an intervention should be less than 120 minutes. In the hospital itself, there should be less than a 60-minute delay. In the pandemic situation, some of these goals are no longer feasible. Due to the protective mechanisms for staff and the general situation, there is a reduction in the standardized quality of care. However, for patients at very high risk, it is still recommended to present them immediately to the cardiac catheterization laboratory (a.k.a. cath lab). "Due to the limited number of intensive care beds, we are often no longer able to maintain our normal referral structures, so we have to accept longer delays." In some cases, patients are transferred to other hospitals that still have capacity. "In Jena [Germany], we had 10% fewer infarctions than in the previous year," Prof. Schulze reported.

Self-presentations in the emergency department were significantly reduced. Severity levels, such as cardiogenic shock, were significantly reduced. Reduced primary care physician contacts were clearly demonstrable. Nevertheless, overall guideline-compliant hospital treatment times were maintained at a high level. And best of all, "There was no increase in infarct mortality in Jena as well as in Germany as a whole," Prof. Schulze highlighted.


DEGIM Congress, 18.4.2021, Session: "COVID-19 - Aspects of Care"

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