Assessment of a Crisis Standards of Care Scoring System for Resource Prioritization and Estimated Excess Mortality by Race, Ethnicity, and Socially Vulnerable Area During a Regional Surge in COVID-19.

Importance: Crisis standards of care (CSOC) scores designed to allocate scarce resources during the COVID-19 pandemic could exacerbate racial disparities in health care. Objective: To analyze the association of a CSOC scoring system with resource prioritization and estimated excess mortality by race, ethnicity, and residence in a socially vulnerable area. Design, Setting, and Participants: This retrospective cohort analysis included adult patients in the intensive care unit during a regional COVID-19 surge from April 13 to May 22, 2020, at 6 hospitals in a health care network in greater Boston, Massachusetts. Participants were scored by acute severity of illness using the Sequential Organ Failure Assessment score and chronic severity of illness using comorbidity and life expectancy scores, and only participants with complete scores were included. The score was ordinal, with cutoff points suggested by the Massachusetts guidelines. Exposures: Race, ethnicity, Social Vulnerability Index. Main Outcomes and Measures: The primary outcome was proportion of patients in the lowest priority score category stratified by self-reported race. Secondary outcomes were discrimination and calibration of the score overall and by race, ethnicity, and neighborhood Social Vulnerability Index. Projected excess deaths were modeled by race, using the priority scoring system and a random lottery. Results: Of 608 patients in the intensive care unit during the study period, 498 had complete data and were included in the analysis; this population had a median (IQR) age of 67 (56-75) years, 191 (38.4%) female participants, 79 (15.9%) Black participants, and 225 patients (45.7%) with COVID-19. The area under the receiver operating characteristic curve for the priority score was 0.79 and was similar across racial groups. Black patients were more likely than others to be in the lowest priority group (12 [15.2%] vs 34 [8.1%]; P = .046). In an exploratory simulation model using the score for ventilator allocation, with only those in the highest priority group receiving ventilators, there were 43.9% excess deaths among Black patients (18 of 41 patients) and 28.6% (58 of 203 patients among all others (P = .05); when the highest and intermediate priority groups received ventilators, there were 4.9% (2 of 41 patients) excess deaths among Black patients and 3.0% (6 of 203) among all others (P = .53). A random lottery resulted in more excess deaths than the score. Conclusions and Relevance: In this study, a CSOC priority score resulted in lower prioritization of Black patients to receive scarce resources. A model using a random lottery resulted in more estimated excess deaths overall without improving equity by race. CSOC policies must be evaluated for their potential association with racial disparities in health care.

Cardiac arrest in the intensive care unit: An assessment of preventability.

AIM: Cardiac arrest in the intensive care unit (ICU-CA) is a common and highly morbid event. We investigated the preventability of ICU-CAs and identified targets for future intervention. METHODS: This was a prospective, observational study of ICU-CAs at a tertiary care center in the United States. For each arrest, the clinical team was surveyed regarding arrest preventability. An expert, multi-disciplinary team of physicians and nurses also reviewed each arrest. Arrests were scored 0 (not at all preventable) to 5 (completely preventable). Arrests were considered 'unlikely but potentially preventable' or 'potentially preventable' if at least 50% of reviewers assigned a score of ≥1 or ≥3 respectively. Themes of preventability were assessed for each arrest. RESULTS: 43 patients experienced an ICU-CA and were included. A total of 14 (32.6%) and 13 (30.2%) arrests were identified as unlikely but potentially preventable by the expert panel and survey respondents respectively, and an additional 11 (25.6%) and 10 (23.3%) arrests were identified as potentially preventable. Timing of response to clinical deterioration, missed/incorrect diagnosis, timing of acidemia correction, timing of escalation to a more senior clinician, and timing of intubation were the most commonly cited contributors to potential preventability. Additional themes identified included the administration of anxiolytics/narcotics for agitation later identified to be due to clinical deterioration and misalignment between team and patient/family perceptions of prognosis and goals-of-care. CONCLUSIONS: ICU-CAs may have preventable elements. Themes of preventability were identified and addressing these themes through data-driven quality improvement initiatives could potentially reduce CA incidence in critically-ill patients.

Quick Sequential Organ Failure Assessment and Systemic Inflammatory Response Syndrome Criteria as Predictors of Critical Care Intervention Among Patients With Suspected Infection.

OBJECTIVES: The Sepsis III clinical criteria for the diagnosis of sepsis rely on scores derived to predict inhospital mortality. In this study, we introduce the novel outcome of "received critical care intervention" and investigate the related predictive performance of both the quick Sequential Organ Failure Assessment and the Systemic Inflammatory Response Syndrome criteria. DESIGN: This was a single-center, retrospective analysis of electronic health records. SETTING: Tertiary care hospital in the United States. PATIENTS: Patients with suspected infection who presented to the emergency department and were admitted to the hospital between January 2010 and December 2014. INTERVENTIONS: Systemic Inflammatory Response Syndrome and quick Sequential Organ Failure Assessment scores were calculated, and their relationships to the receipt of critical care intervention and inhospital mortality were determined. MEASUREMENT AND MAIN RESULTS: A total of 24,164 patients were included of whom 6,693 (27.7%) were admitted to an ICU within 48 hours; 4,453 (66.5%) patients admitted to the ICU received a critical care intervention. Among those with quick Sequential Organ Failure Assessment less than 2, 13.4% received a critical care intervention and 3.5% died compared with 48.2% and 13.4%, respectively, for quick Sequential Organ Failure Assessment greater than or equal to 2. The area under the receiver operating characteristic was similar whether quick Sequential Organ Failure Assessment was used to predict receipt of critical care intervention or inhospital mortality (0.74 [95% CI, 0.73-0.74] vs 0.71 [0.69-0.72]). The area under the receiver operating characteristic of Systemic Inflammatory Response Syndrome for critical care intervention (0.69) and mortality (0.66) was lower than that for quick Sequential Organ Failure Assessment (p < 0.001 for both outcomes). The sensitivity of quick Sequential Organ Failure Assessment for predicting critical care intervention was 38%. CONCLUSIONS: Emergency department patients with suspected infection and low quick Sequential Organ Failure Assessment scores frequently receive critical care interventions. The misclassification of these patients as "low risk," in combination with the low sensitivity of quick Sequential Organ Failure Assessment greater than or equal to 2, may diminish the clinical utility of the quick Sequential Organ Failure Assessment score for patients with suspected infection in the emergency department.