The victims of the unprecedented coronavirus disease-2019 (COVID-19) pandemic show the clinical manifestations of a severe acute respiratory distress syndrome (ARDS) and have high rates of ventilator-dependence1 that put a heavy burden on local and national healthcare systems. The high number of critically ill patients has forced the triage of a range of hospital resources from personal protective equipment to beds and intensive care personnel.2 The practical allocation of critical care beds and resources is challenging for those on the front line of patient care, although there have been some recommendations for the allocation of limited resources.2,3
The emergence of COVID-19 has dramatically increased the burden on healthcare systems and the need for dedicated critical care, beds, and mechanical ventilation. Across Europe, a highly heterogeneous distribution of critically ill patients with COVID-19 has been observed.4 As a result there have been inequalities regarding the availability of intensive care beds and equipment beneficial for patients with COVID-19. Already a reality in some countries, the COVID-19 pandemic has led to an ‘absolute shortage’ of resources.5 Most physicians in Europe have not previously faced the difficult resource constraints that the current pandemic imposes. Mass casualty events (MSE), such as the current COVID-19 pandemic, can generate many critically ill patients that can overwhelm healthcare systems.6 When there are limited medical resources, recommendations for the preparation and management of such MSEs have suggested the use of a triage system for the fair and adequate allocation of the available resources.7,8 However, these recommendations tend to be based on ethical triage systems9,10 and do not address mechanisms that might balance overcapacity and overload of some healthcare system with availability in others, as seen during the current pandemic.5
To assess the acceptance of allocation strategies for managing patients and limited resources for critical care that are not based on ethical triage, but on existing international capacity, we conducted a survey sent to the representative bodies [National Anaesthesiologists Societies Committee (NASC) and Council] of the European Society of Anaesthesiology and Intensive Care (ESAIC). This group of experienced national key opinion leaders, anaesthesiologists and intensivists, across European borders, were invited to respond by polling their attitudes and opinions on the use of limited critical care resources during the current crisis. The objective of this study was to provide expert opinions and guidance to facilitate the (ethical) burden currently facing our colleagues on the front line of this pandemic.
No ethical approval was required for this survey.
In order to establish management strategies that address the existing inequalities of limited critical care resources, a web-based questionnaire was prepared. Our sample consisted of all European anaesthesiology societies represented by the corresponding NASC member (president or past-president of the national society) and national council member of the (ESAIC). Respondents came from the following 42 countries represented in the European Society of Anaesthesiology and Intensive Care: Albania, Armenia, Austria, Belgium, Bosnia-Herzegovina, Bulgaria, Croatia, Cyprus, Czech Rep., Denmark, Estonia, Finland, France, Georgia, Germany, Greece, Hungary, Ireland, Israel, Italy, Kosovo, Latvia, Lithuania, Malta, Montenegro, Netherlands, Norway, Poland, Portugal, Rep. North Macedonia, Rep. of Moldova, Romania, Russia, Serbia, Slovakia, Slovenia, Spain, Sweden, Switzerland, Turkey, United Kingdom and Ukraine.
The survey consisted of 10 questions related to the organisation of COVID-19-infected patients and different strategies regarding the management of the existing critical care resources (Supplement 1 for individual questions, http://links.lww.com/EJA/A473). Responses were analysed thematically.
A total of 74 (92.5%) NASC and Council members of the ESAIC throughout Europe responded to our survey (Supplement 1, http://links.lww.com/EJA/A473). Of these, 83.8% specified working in a university hospital, 9.5% in acute care hospitals and 6.8% in other hospitals. Out of all respondents, 83.8% were involved in the treatment of COVID-19-infected patients and 58.1% represented the responsible department for their treatment. The specialists primarily in charge for COVID-19 were predominantly anaesthesiologists and critical care specialists (45.1%). Infectious disease specialists were responsible for the treatment of COVID-19-infected patients in 29% and internal medicine physicians in 16.1% of responses.
A total of 74% of respondents reported that intensive care beds were available for the treatment of patients with COVID-19 infection at the time of the survey. More than half (58.9%) of the representatives of the ESAIC were in favour of making excess critical care capacity available to others. Of those representatives, 69% supported making excess capacity available to supraregional patients potentially needing treatment of COVID-19 infection, whereas 30.9% preferred to keep the resources available for the local population, the treatment of non-COVID-19 patients requiring critical care treatment.
According to 35.3% of respondents, any overcapacity of critical care beds should be made available to supraregional and/or international patients. Concerning the allocation of medical equipment and/or resources, 32.4% answered that these should be made available to sites in need and 32.4% agreed with both options.
Concerning the allocation of overcapacity, 23.8% preferred a self-initiated contact between critical care physicians, whereas 59.5% favoured a centralised European (political and medical) and 16.6% a national allocation system.
Strategies to manage critical care capacity during the COVID-19 pandemic may be politically charged and ethically controversial. They pose tremendous challenges for both healthcare providers and policy makers. As critical care bed numbers vary considerably between countries in Europe, an international platform that provides a dialogue on free, available and restricted resources should facilitate the planning and use of critical care resources in the future.11
We have demonstrated that the predominant opinion of the national NASC and council representatives of the ESAIC is that there should be supra-regional provision of existing critical care supply resources. This finding reinforces the concept of an organised structure to monitor the range of supply resources at an international level and to develop allocation strategies to provide optimal care for critically ill patients (Fig. 1). Our results suggest that there may be differences in the way in which countries approach healthcare issues in MSE, such as during the current COVID-19 pandemic. As we are confident that participants have understood and dealt with the principles discussed, these differences are likely to be based on national conditions, which need to be recorded in detail and processed in a structured manner.
The main finding of an emerging readiness to share critical care resources underscores the importance of establishing systemic methodologies for further MSEs, such as a possible second wave of the COVID-19 pandemic. The aim, in such an event, should be to assess and ultimately restructure inequalities of critical care supply resources to address shortages in the availability of critical care beds (Fig. 1).
Although existing recommendations regarding the allocation of scarce resources primarily consider ethical aspects, a generally valid strategic instrument for the supraregional allocation of resources and patients is not yet available.
In this respect, a lesson can be drawn from the regional and national approach in Italy. By structuring staff units with supraregional administrative authority, specific algorithms with detailed protocols and specialised teams, it was possible to control the patient flow in Milan to deal with specific issues of bed resources and emergency department overcrowding.12 However, the devastating experience in Italy demonstrates the limitations that can exist on a national level, despite the greatest efforts.13 This underlines the high sense of urgency perceived among physicians across Europe in establishing a structure for re-allocating patients and medical equipment, though any such re-allocation needs to be carefully considered in light of a potential surge of COVID-19 patients in the local population.
In summary, Europe needs a tool to match the supply and demand of ICU beds for COVID-19 patients of the local population, based on infection rates and length of stay. Where demand exceeds supply, patients should be re-allocated on a supraregional basis in close collaboration with the specialties responsible for treating patients with COVID-19 who are citizens of the European Union.14,15 With such a tool, health authorities and elected officials would be better prepared to shape and communicate the principles for optimised patient care and health service allocation. Previous pandemics have failed to provide pertinent evidence that could guide physicians and medical administrators in their management of the current crisis.
The ESAIC as the leading European professional organisation for anaesthesiology and intensive care medicine could learn from national and international experiences and make recommendations for structuring the supraregional mechanisms required. Its considerable expertise could support regional and national organisations in their implementation.
In conclusion, a system should be established to balance the allocation of critical care patients from where demand exceeds supply to where there is overcapacity. In Europe, this would be appropriately organised by a suitable political and medical institution to be implemented in the event of future crises requiring medical treatment beyond locally available capacity.
Acknowledgements relating to this article
Assistance with the study: we would like to thank the NASC and council members of the ESAIC and the ESAIC staff for their assistance with this survey. We are extremely grateful to all our nurses and support personnel on the front line for their compassionate and co-operative care of all COVID-19 patients.
Financial support and sponsorship: none.
Conflicts of interest: none.
1. Guan W-j, Ni Z-y, Hu Y, et al. China Medical Treatment Expert Group for Covid-19. Clinical characteristics of coronavirus disease 2019 in China. N Engl J Med
2. Truog RD, Mitchell C, Daley GQ. The toughest triage—allocating ventilators in a pandemic. New Engl J Med
3. Biddison ELD, Faden R, Gwon HS, et al. Too many patients… a framework to guide statewide allocation of scarce mechanical ventilation during disasters. Chest
4. Oksanen A, Kaakinen M, Latikka R, et al. Regulation and trust: 3-month follow-up study on COVID-19 mortality in 25 European countries. JMIR Public Health Surveill
5. Emanuel EJ, Persad G, Upshur R, et al. Fair allocation of scarce medical resources in the time of Covid-19. New Engl J Med
6. Fauci AS. Seasonal and pandemic influenza preparedness: science and countermeasures. J Infect Dis
2006; 194: (Suppl 2): S73–S76.
7. Hick JL, O’Laughlin DT. Concept of operations for triage of mechanical ventilation in an epidemic. Acad Emerg Med
8. Christian MD, Joynt GM, Hick JL, et al. European Society of Intensive Care Medicine's Task Force for intensive care unit triage during an influenza epidemic or mass disaster. Chapter 7. Critical care triage. Recommendations and standard operating procedures for intensive care unit and hospital preparations for an influenza epidemic or mass disaster. Intensive Care Med
2010; 36 Suppl 1:S55–S64.
9. Christian MD, Sprung CL, King MA, et al. Task Force for Mass Critical Care, Task Force for Mass Critical Care. Triage: care of the critically ill and injured during pandemics and disasters: CHEST Consensus Statement. CHEST
10. Gomersall CD, Tai DY, Loo S, et al. Expanding ICU facilities in an epidemic: recommendations based on experience from the SARS epidemic in Hong Kong and Singapore. Intensive Care Med
11. Rhodes A, Ferdinande P, Flaatten H, et al. The variability of critical care bed numbers in Europe. Intensive Care Med
12. Spina S, Marrazzo F, Migliari M, et al. The response of Milan's Emergency Medical System to the COVID-19 outbreak in Italy. Lancet
13. Armocida B, Formenti B, Ussai S, et al. The Italian health system and the COVID-19 challenge. Lancet Public Health
14. Lazzerini M, Putoto G. COVID-19 in Italy: momentous decisions and many uncertainties. Lancet Glob Health
15. Bucciardini R, Contoli B, De Castro P, et al. The health equity in all policies (HEiAP) approach before and beyond the Covid-19 pandemic in the Italian context. Int J Equity Health