Medical Triage in Saskatchewan January 4, 2022
There are 4 stages of medical triage to be considered. Saskatchewan is now in the 2nd stage. The segments I took from the Saskatchewan Health Authority’s website seem to address some concerns..
SOURCE FOR INFO BELOW: The Saskatchewan Critical Care Resource Allocation Framework.pdf (saskhealthauthority.ca)
Clinical Frailty Scale Score Description
1 Very Fit – People who are robust, active, energetic and motivated. These people commonly exercise regularly. They are among the fittest for their age.
2 Well – People who have no active disease symptoms but are less fit than category 1. Often, they exercise or are very active occasionally, e.g. seasonally.
3 Managing Well – People whose medical problems are well controlled, but are not regularly active beyond routine walking.
4 Vulnerable – While not dependent on others for daily help, often symptoms limit activities. A common complaint is being “slowed up”, and/or being tired during the day.
5 Mildly Frail – These people often have more evident slowing, and need help in high order IADLs (finances, transportation, heavy housework, medications). Typically, mild frailty progressively impairs shopping and walking outside alone, meal preparation and housework.
6 Moderately Frail – People need help with all outside activities and with keeping house. Inside, they often have problems with stairs and need help with bathing and might need minimal assistance (cuing, standby) with dressing.
7 Severely Frail – Completely dependent for personal care, from whatever cause (physical or cognitive). Even so, they seem stable and not at high risk of dying (within ~ 6 months).
8 Very Severely Frail – Completely dependent, approaching the end of life. Typically, they could not recover even from a minor illness.
9 Terminally Ill – Approaching the end of life. This category applies to people with a life expectancy < 6 months, who are not otherwise evidently frail.
Critical care triage stage 4 protocol for patients with coronavirus disease 2019 in Saskatchewan. Note: ACP = advance care planning, Fio2 = fraction of inspired oxygen, GOC = goals of care, SOFA = Sequential Organ Failure Assessment, Spo2 = oxygen saturation. Extracorporeal life support (ECLS) may provide effective treatment for refractory cases, but it requires extensive resources. Each request for ECLS will be reviewed by at least 2 ECLS experts, in addition to the triage team. These ECLS experts will be designated by the area leads of the Department of Critical Care (Regina and Saskatoon). The number of patients that can be placed on ECLS is small and should be decided on a case-by-case basis. Definite exclusion criteria include age older than 60 years; receiving mechanical ventilation for more than 7 days; irreversible neurologic, multiorgan failure; malignancy; cardiac arrest; severe end-stage liver, lung, kidney or heart disease; advanced neurocognitive disease; pregnancy; body mass index > 45; inability to receive anticoagulation or blood products; or ECLS resources not available in city. Legend: red = highest priority patient (most likely to benefit from admission to the intensive care unit [ICU]), yellow = intermediate priority patient (may benefit from ICU care), green = patient does not require ICU care (too well), blue = palliative care only (poor prognosis is likely).
We designed our framework to maximize survival to hospital discharge, given its acceptance in other resource allocation frameworks and studies.7,9,11 Members of our working group agreed that maximizing life-years saved could potentially unfairly disadvantage older adults, patients with disabilities and patients with chronic conditions. However, criteria were included within the framework that could serve as tiebreakers, in the following order of priority: physiologic criteria, life-cycle and instrumental value criteria (Figure 1, Table 1). Tiebreaker criteria would be used when 2 patients present with identical clinical and physiologic situations. For example, if a healthy 50-year-old and a healthy 70-year-old both require ICU care and have a Sequential Organ Failure Assessment (SOFA) score of 5, the life-year tiebreaker criterion would be used to offer the 50-year-old an ICU bed first.
Importantly, quality-of-life considerations should not factor into resource allocation decisions.12 First, quality-of-life judgments may unfairly disadvantage older adults, patients who require long-term ventilation and patients with disabilities. Second, during a pandemic, it may not be possible to determine future quality of life before the institution of life-supportive therapy owing to severe time and resource constraints.10 Most importantly, quality-of-life considerations are most relevant in the shared decision-making paradigm, where the patient may refuse care because it would leave them with an unacceptable quality of life. The acceptability of a certain quality of life is solely the patient’s purview. In pandemic situations where autonomy is not at the forefront of ethical decision-making, the patient may refuse ICU care, but physicians should not make this judgment on behalf of the patient unilaterally.
Special populations such as older adults, patients who are undergoing long-term ventilation, health care workers, patients who are pregnant and patients with disabilities require specific considerations and solutions (Table 2).