Intensive care unit overloaded: when does the triage take effect?

The effects of the corona pandemic can be seen in a wide variety of areas. Hospitals and intensive care units are particularly affected by the rising incidence figures and increasing serious infections. The clinics are reaching their limits. Operations already have to be postponed. But when is the capacity fully utilized and how is it decided who will be treated?

The word triage comes from French and is used in the medical field. This describes the classification of injured or ill people depending on the degree of injury or illness, the pain and suffering.

Overwhelming Hospitals: What the Triage Means

The increase in the number of seriously ill people leads to full intensive care units and the utilization of hospitals. People with severe illnesses in particular need intensive care from medical staff and doctors and usually access to ventilators. If the health system reaches its limits, the treatment options should be distributed according to a certain system. Otherwise, physicians have to decide who is to be treated and who is not – in this case, the triage system comes into play.

Originally, the principle of triage was mostly used in military medicine and is now mostly used in emergency rooms. Accordingly, people with particularly serious injuries are treated first.

In exceptional situations, however, this method can change, such as in war. The goal is then to save as many lives as possible despite scarce resources by giving priority to treating people with a higher chance of survival. However, doctors usually find it very difficult to apply the principle, as this violates their professional ethics.

The triage: who decides who gets treated?

In order to relieve medical professionals and doctors, seven medical societies published the first recommendation, which defines, among other things, treatment criteria and priorities for the treatment of COVID-19 disease in intensive care units. This recommendation also has the status of an S1 guideline, which is based on the opinion and knowledge of experts, but does not refer to current studies. The ethics committee of the German Interdisciplinary Association for Intensive Care Medicine (DIVI) also played a major role in the development of these guidelines.

Guidelines serve as a decision-making aid for the treating physicians, but are not generally applicable laws. When worded accordingly, they nevertheless reflect medical standards, which in turn are binding and relevant.

In an emergency, doctors should follow the guidelines in order to be protected from criminal consequences.

The most important thought of the triage or the guideline is: The faster the recovery process, the sooner a place will be free for new patients. Doctors should therefore observe the following points when treating those affected:

  • general health of the person
  • severity of the disease
  • Concomitant diseases and pre-existing conditions that worsen the diagnosis

The age of the patient and social factors such as income, level of education or status in society must not play a role in this context.

A doctor never makes decisions alone: ​​at least two doctors on the ward and an experienced part of the nursing staff are recommended.

In addition, decision-making criteria are checked and re-evaluated in the course of treatment and on a case-by-case basis.

Medical experts speak of prioritization

Even before the intensive care units are fully utilized, the triage system begins to take effect – doctors therefore often prefer to speak of prioritization. Because the medical staff not only decides about life and death. Instead, prioritization takes place depending on the state of health and the urgency of the treatment.

In addition to COVID-19 sufferers, medical emergencies such as  heart attacksstrokes , accidents and other serious illnesses must still be treated. In the case of overloaded wards, however, not all those affected can be allocated a bed in the intensive care unit. In these cases, it is necessary to prioritize who gets an intensive care bed or who could stay and be cared for in a normal ward.

Cancer patients are also often affected by the consequences of hospital overload, since  operations that have already been planned  have to be postponed. However, this postponement must not result in a deterioration in the state of health.

Intensive care beds: Vaccination status has no influence

The German Society for Internal Intensive Care Medicine and Emergency Medicine (DGIIN) is clearly against the  SARS-CoV-2  vaccination status as the basis for a medical treatment decision. Doctors are obliged to provide medical assistance, the behavior of the person concerned before treatment plays a subordinate role.

Severe COVID-19 diseases generally have a low chance of survival, and this is usually even lower for unvaccinated people. If these people are connected to a ventilator, the probability of survival drops to around half.

A vaccine breakthrough, for example, can lead to a better prognosis in otherwise healthy, older people than severe COVID-19 illness in younger unvaccinated people with pre-existing conditions. So if there is a better chance of survival for the vaccinated person, this could be preferred in the system based on the defined criteria.

Overall, the DGIIN press release states: “Social characteristics, age, religion, underlying diseases or disabilities, but also personal backgrounds and attitudes of the patients must not influence the decisions in the course of treatment.”

 

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