Ventilator allocation guidelines among states vary widely
A new study highlights significant variation in ventilator allocation guidelines among U.S. states, which could result in inequity in the allocation of mechanical ventilatory support during the COVID-19 pandemic.
“Only 26 U.S. states have ventilator allocation guidelines if a ventilator shortage occurs, which could occur with a second wave of the COVID-19 pandemic. These state ventilator allocation guidelines vary widely and will lead to inequity of allocation,” Gina M. Piscitello, MD, assistant professor in the department of internal medicine and section of palliative medicine at Rush Medical College, told Healio.
Piscitello and colleagues conducted a systematic review to evaluate publicly available guidelines on ventilator allocation for all U.S. states and the District of Columbia using state department of health websites and internet research. Any documents discussing a process assigning mechanical ventilatory support during public health emergencies were screened for inclusion in the review. All accepted documentation was assessed by two independent reviewers.
In total, 27 guidelines were included in the systematic review (26 state protocols, one pediatric-specific state protocol).
Twenty-six states had publicly available ventilator guidelines and 14 states had pediatric guidelines, as of May 10. Of the 26 states with mechanical ventilator guidelines, 24 (92%) recommended an objective scoring system for allocation. Inclusion of the Sequential Organ Failure Assessment (SOFA) score was recommended in 15 guidelines (58%) for ventilator allocation and assessment of limited life expectancy from underlying conditions/comorbidities was included in six guidelines (23%), according to the results.
Guidelines in six states (23%) recommended priority for specific groups during the initial evaluations; the states were Illinois, Maryland, Massachusetts, Michigan, Pennsylvania and Utah. Three guidelines (12%) in Illinois, Michigan and Pennsylvania recommended giving priority to heath care workers and others in roles vital to public health, according to the results.
Eleven (42%) adult guidelines and 10 (71%) pediatric guidelines recommended exclusion criteria for mechanical ventilator allocation. Withdrawal of ventilation from one patient to another during a shortage was mentioned in 22 (85%) adult guidelines and nine (64%) pediatric guidelines, according to the results.
“If a ventilator shortage were to occur, a patient presenting to a hospital in one state may be at higher priority for a ventilator than a patient presenting in another state due to seemingly arbitrary differences in exclusion criteria, scoring systems and priority groups among states,” Piscitello told Healio.
“An example from the paper is a patient with a SOFA score of 6 and a severe life-limiting condition with death likely within 1 year would be at intermediate priority for a ventilator if they presented to a hospital in Pennsylvania, but would be at high priority for a ventilator if they presented across the border in neighboring New York,” she said. “In addition, based on some state guidelines, people meeting certain criteria such as severe dementia, metastatic malignancy and children with metabolic or chromosomal anomalies would be automatically excluded from consideration for a ventilator without a change to receive a priority score based on their overall health status.”
Moving forward, Piscitello said U.S. state departments of health could look at these findings and “try to find a way to work together to create more uniform guidelines throughout the United States to prevent disparities from occurring from one state to another.”
“I look forward to seeing future research in the variety of guidelines among hospitals throughout the United States, as many hospitals had no state guidance and even those that were not mandated to follow state guidelines,” she said.