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Pediatric Triage in a Severe Pandemic: Maximizing Survival by Establishing Triage Thresholds*

Gall, Christine DrPH1; Wetzel, Randall MBBS1,2; Kolker, Alexander PhD3; Kanter, Robert K. MD4,5; Toltzis, Philip MD6,7

doi: 10.1097/CCM.0000000000001759
Pediatric Critical Care
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Objectives: To develop and validate an algorithm to guide selection of patients for pediatric critical care admission during a severe pandemic when Crisis Standards of Care are implemented.

Design: Retrospective observational study using secondary data.

Patients: Children admitted to VPS-participating PICUs between 2009–2012.

Interventions: A total of 111,174 randomly selected nonelective cases from the Virtual PICU Systems database were used to estimate each patient’s probability of death and duration of ventilation employing previously derived predictive equations. Using real and projected statistics for the State of Ohio as an example, triage thresholds were established for casualty volumes ranging from 5,000 to 10,000 for a modeled pandemic with peak duration of 6 weeks and 280 pediatric intensive care beds. The goal was to simultaneously maximize casualty survival and bed occupancy. Discrete Event Simulation was used to determine triage thresholds for probability of death and duration of ventilation as a function of casualty volume and the total number of available beds. Simulation was employed to compare survival between the proposed triage algorithm and a first come first served distribution of scarce resources.

Measurements and Main Results: Population survival was greater using the triage thresholds compared with a first come first served strategy. In this model, for five, six, seven, eight, and 10 thousand casualties, the triage algorithm increased the number of lives saved by 284, 386, 547, 746, and 1,089, respectively, compared with first come first served (all p < 0.001).

Conclusions: Use of triage thresholds based on probability of death and duration of mechanical ventilation determined from actual critically ill children’s data demonstrated superior population survival during a simulated overwhelming pandemic.

1Virtual PICU Systems, LLC, Los Angeles, CA.

2Department of Pediatrics and Anesthesiology, Children’s Hospital Los Angeles, USC Keck School of Medicine, Los Angeles, CA.

3API Healthcare, A GE Healthcare Company, Hartford, WI.

4Department of Pediatrics, Virginia Tech Carilion School of Medicine, Roanoke, VA.

5National Center for Disaster Preparedness, Columbia University, New York, NY.

6Case Western University School of Medicine, Cleveland, OH.

7Rainbow Babies and Children’s Hospital, Cleveland, OH.

*See also p. 1793.

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Supported, in part, through contract with the Ohio Hospital Association. The authors have no further financial disclosures or conflicts of interest.

Dr. Gall’s institution received funding from the Ohio Hospital Association. She was employed by Virtual Pediatric Systems (VPS) as Director, Quality and Client Relations, while this research was conducted, and is grateful for the support and expertise provided by her VPS colleagues. Dr. Wetzel is the uncompensated CEO of VPS, LLC who provided the data for this study. He received support for article research from the Ohio Hospital Association. His institution received funding from the Ohio Hospital Association. Dr. Kolker received funding from the Ohio Hospital Association. Dr. Toltzis’ institution received funding from the Ohio Hospital Association and the Agency for Healthcare Research and Quality. Dr. Kanter disclosed that he does not have any potential conflicts of interest.

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