Intensive care medicine: triage under resource scarcity – chronology

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The guidelines «COVID-19 pandemic: triage for intensive-care treatment under resource scarcity» were published on 20 March 2020 by the SAMS, together with the Swiss Society for Intensive Care Medicine (SGI). They will be continuously adapted if experience in practice or new scientific findings so require. On this page you can find all versions in all four languages.

The latest version of the guidelines as well as other relevant documents and background information can be found here.

 

Significant clarifications from version 3 to version 3.1

The latest version of the guidelines (3.1) explains in more detail the principle of the short-term survival prognosis, which is crucial for triage decisions. For example, it is more explicitly emphasised that the aim is always to make decisions in such a way as to ensure that as few people die as possible. Also highlighted is the need for careful consideration of, and re-evaluation of treatment in the light of, the patient’s wishes.

 

In addition, legal aspects are clarified: the discussion of the unacceptability of age, disability and dementia as criteria for triage decisions, as well as the application of the Clinical Frailty Scale, was not sufficiently detailed in the previous version, which gave rise to some misunderstandings. These sections have now been expanded or reworded, partly in consultation with the relevant organisations.

 

Additionally taken into account is the experience that – despite an increase in ICU beds, the suspension of elective procedures and the involvement of the national body responsible for coordination of patient transfers – application of the guidelines may become unavoidable at the local or regional level before the threshold for triage decisions has been reached at the national level.

 

The recommendations for the work and decision-making of ICU professionals (Sections 4.3 and 4.4) are essentially unchanged, although they have been clarified on the basis of experience accumulated during the pandemic.

 

 

Significant clarifications from version 2 to version 3

One key change concerns the national coordination body which has since been established by the federal authorities. This is to ensure that optimum use is made of all ICU treatment capacity available across Switzerland.

 

One important clarification concerns age. As in the previous version, it is stated that age in itself is not to be used as a triage criterion; the same applies to disability or dementia. Such factors may, however, be indicative of a person’s general physical condition. To allow this to be better evaluated, the guidelines now also take frailty into account. The (validated) 9-point Clinical Frailty Scale represents an additional useful tool.

 

Additional points have been included in the list of triage criteria for ICU admission/continuation of ICU treatment (Sections 4.3 and 4.4).

 

 

 

Significant clarifications from version 1 to version 2

The two stages (A and B) defined in the Box on page 4 of the guidelines remain fundamental:

 

Stage A: ICU beds available, but capacity limited
→ Admission triage/resource management through decisions on discontinuation of treatment

 

Stage B: No ICU beds available
→ Admission triage/resource management through decisions on discontinuation of treatment

 

Clarifications

Stage A: New wording for malignant disease: rather than “metastatic malignant disease”, the guidelines now refer to “malignant disease with a life expectancy of less than 12 months”.

 

Stage A: Distinction between existing and newly arising organ failure. The decisive factor is not whether the patient already has an organ failure on admission, but the occurrence of a new significant organ failure.

 

Stages A and B: Refinement of the triage criteria for patients with COPD.

 

 

 

 

 

 

CONTACT

Dr. iur. Thomas Gruberski
Head Department Ethics