Medical Isolationism in Hawaii

Hawaii puts all future entrants to the state on mandatory 14-day quarantine this season. This seems reasonable, as virtually all cases so far have been in visitors or, especially, residents who returned from trips away from the islands.

Here.

Plague Ship

The Big Island has had its first confirmed SARS-CoV-2 case confirmed today: rumor has it that it was one of two visitors who jumped ship from the ill fated Diamond Princess cruise ship when it docked in Hilo about two weeks ago.

LAVA: 24 seconds for hand washing

Who would have thought that the chorus to Lava would make a good handwashing timing song? For your hand washing entertainment, here.

COVID TRIAGE IN ITALY, MARCH 2020

The below is a translation of the official Italian document. Here is the original: Italian PDF

With current projections of the coronavirus epidemic (COVID-19) currently underway in some Italian regions, there are estimates of an increase in cases of acute respiratory failure in the next few weeks in many centers (with need for ICU admission) of such magnitude as to cause an enormous imbalance between the real clinical needs of the population and the actual availability of intensive resources.

It is a scenario where criteria for access to intensive care (and discharge) may be needed not only strictly according to clinical appropriateness and proportionality of care, but also inspired by shared criterions of distributive justice and appropriate allocation of resources under conditions of limited healthcare.

A scenario of this kind can be substantially assimilated to the field of "disaster medicine", for which ethical reflection has over time developed many concrete indications for doctors and doctors nurses engaged in difficult choices. As an extension of the principle of proportionality of care, allocation in a context of a serious shortage of health resources must aim at guaranteeing intensive treatments to patients with greater chances of therapeutic success: it is therefore a matter of privileging the "greatest life expectancy ".

The need for intensive care must therefore be integrated with other elements of "clinical suitability" to intensive care, thus including: the type and severity of the disease, the presence of comorbidities, the impairment of other organs and systems and their reversibility. This means not necessarily having to follow a criterion for access to intensive care like "first come, first served". It is understandable that the carers, by culture and training, are not accustomed to reasoning with criteria of maxi-emergency triage, as the current situation has exceptional characteristics. The availability of resources does not usually enter the decision-making process and the choices of the individual case, until resources become so scarce as to not allow to treat all patients who they could hypothetically benefit from a specific clinical treatment. It is implicit that the application of rationing criteria is justifiable only after all the subjects involved (in particular the "Crisis Units" and the governing bodies of hospital facilities) have made all possible efforts to increase the availability of resources available (in particular, Intensive Care beds) and after any possibility of transfer of the patients to centers with greater availability of resources.

It is important that a change in access policies should be shared as much as possible among the operators involved. Patients and their families interested in applying the criteria must be informed of the extraordinary nature of the measures in place, due to a question of duty of transparency and maintenance of trust in the public health service.

The purpose of the recommendations is also to:

(A) to relieve clinicians from a part of responsibility in choices, which can be emotionally burdensome, carried out in individual cases;

(B) to make the allocation criteria for healthcare resources explicit in a condition of their own extraordinary scarcity.

From the information available now, a substantial part of subjects diagnosed with infection from Covid-19 requires ventilatory support due to interstitial pneumonia characterized by severe hypoxemia. Interstitial disease is potentially reversible, but the acute phase can last many days. Unlike more familiar ARDS cadres, with the same hypoxemia, Covid-19 pneumonia appears to have slightly better lung compliance and respond better to recruitment, medium PEEP, pronation cycles, inhaled nitric oxide. As for the most well-known paintings of habitual ARDS, these patients require protective ventilation, with low driving pressure.

All this implies that the intensity of care can be high, as well as the use of human resources. From the data reported for the first two weeks in Italy, about one tenth of infected patients require intensive care treatment with assisted ventilation, invasive or non-invasive.

RECOMMENDATIONS

1. Extraordinary admission and discharge criteria are flexible and can be adapted locally the availability of resources, the real possibility of transferring patients, the number of accesses in progress or expected. The criteria apply to all intensive patients, not only to patients infected with Covid-19 infection.

2. Allocation is a complex and very delicate choice, also due to the fact that an excessive increase Extraordinary intensive beds would not ensure adequate care for individual patients and would distract resources, attention and energy to the remaining patients admitted to Intensive Care. It is to be considered also the foreseeable increase in mortality due to clinical conditions not linked to the ongoing epidemic, due to the reduction of surgical and outpatient elective activity and the scarcity of intensive resources.

3. It may be necessary to place an age limit on entry into ICU. It is not a question of making choices merely of value, but to reserve resources that could be very scarce first, for those who are primarily more likely to survive and second, for those who can have more years of life saved, with a view to maximizing of benefits for most people.

In a scenario of total saturation of intensive resources, to decide to keep a criterion of "First come, first served" would still amount to choosing not to treat any subsequent patients that would be excluded from Intensive Care.

4. The presence of comorbidities and functional status must be carefully evaluated, in addition to age registry. It is conceivable that a relatively short course in healthy people will potentially become longer and therefore more resource consuming on the health service in the case of elderly, frail or disabled patients or in those with severe comorbidity.

The specific and general clinical criteria which can be particularly useful for this purpose can be seen in the 2013 multi-company SIAARTI document on major end-stage organ failure (https://bit.ly/2Ifkphd). It is also appropriate to refer also to the SIAARTI document relating to the admission criteria in intensive care (Minerva Anestesiol 2003; 69 (3): 101–118)

5. Care should be taken as to the possible presence of a living will previously expressed by the patients through any DAT (advance treatment provisions) and, in particular, any end-of-life preferences that may have already been expressed (by patients and their caregivers) by people who are have already gone through care planning in the case of prior chronic disease.

6. For patients for whom access to an intensive course is deemed "inappropriate", the decision to set a ceiling of care should be motivated, communicated and documented. The ceiling of care placed before mechanical ventilation must not preclude intensity of inferior care.

7. Any judgment of inappropriateness in accessing intensive care based solely on criteria of distributive justice (extreme imbalance between demand and availability) should find justification in the extraordinary nature of the situation.

8. In the decision-making process, if situations of particular difficulty and uncertainty arise, it can be useful to have a "second opinion" (possibly even by phone) from interlocutors of particular experience (for example, through the Regional Coordination Center).

9. The criteria for access to Intensive Care should be discussed and defined for each patient in the most possible way possible early, ideally creating in time a list of patients who will be deemed worthy of Intensive Care at the moment in which the clinical deterioration occurred, provided that the availability at that moment allow it.

Any “do not intubate” instruction should be present in the medical record, ready for be used as a guide if clinical deterioration occurs precipitously and in the presence of caregivers who have not participated in the planning and who do not know the patient.

10. Palliative sedation in hypoxic patients with disease progression is considered necessary as an expression of good clinical practice, and must follow existing recommendations. If there is a need for provision for a not short agonic period, a transfer to a nonintensive environment must be provided.

11. All accesses to intensive care must however be considered and communicated as an "ICU trial" and therefore undergo daily reassessment of appropriateness, goals of care and proportionality of care. If it is considered that a patient, perhaps hospitalized with borderline criteria, does not respond to prolonged initial treatment or is severely complicated by a decision by "Therapeutic desistance" and remodulation of intensive to palliative care - in a scenario of exceptionally high influx of patients - should not be postponed.

12. The decision to limit intensive care should be discussed and shared as collegially as possible of the treating team and - as far as possible - in dialogue with the patient (and family members), but must be able to be timely. It is foreseeable that the need to make choices of this type repeatedly will pay off in each stronger ICU the decision-making process is better adaptable to the availability of resources.

13. ECMO support, as it is resource consuming compared to an ordinary ICU hospitalization, in conditions of extraordinary influx, should be reserved for extremely selected cases and with relatively rapid weaning forecast. It should ideally be reserved for hub centers at high volume, for which the patient in ECMO absorbs proportionately fewer resources than there are would absorb in a center with less expertise.

14. It is important to "network" through the aggregation and exchange of information between centers and individual professionals. When the working conditions allow it, at the end of the emergency, it will be important to dedicate time and resources to debriefing and monitoring any burnout professional and moral distress of operators.

15. Considerateness should be exercised for family members of those hospitalized in ICU with Covid-19, especially in cases in which the patient dies at the end of a total visit restriction period.