A member asked us about intensive care unit (ICU) utilization and ventilator utilization and allocation in the ICU during the coronavirus 2019 (COVID-19) pandemic. Factors that may inform decision-making about ventilator allocation and ICU capacity include patient age, presence of comorbidities, expected survival, and patients' advance directives. Alternative ventilators may also be used.
Ventilator Utilization
Organizations should perform an inventory of all their available mechanical ventilator devices and supplies, including those that are in service, those in storage, and those that the facility anticipates receiving through purchases, rentals, donations, and emergency stockpiles. This inventory should include machines from ambulatory surgery centers and other locations that could be used to treat patients during a pandemic. All personnel who could help treat patients on ventilators, including those working in ambulatory and other centers, should also be identified.
If the inventory reveals that the number of ventilators is low, the organization should consider alternatives.
ECRI's suggested ventilator selection sequence is as follows:
- Intensive care ventilators
- Advanced transport/subacute/home care ventilators that have intensive care features and are capable of treating patients with acute respiratory distress syndrome (ARDS)
- Anesthesia units
- Basic transport/subacute/home care ventilators
- Hospital noninvasive ventilators
- Modified home bilevel positive-airway-pressure (BiPAP) sleep apnea therapy devices
- Unmodified home BiPAP sleep apnea therapy devices
- If all other alternatives are exhausted: a single ventilator split between two or more patients, for short-term use—however, this strategy has significant limitations
The Centers for Disease Control and Prevention (CDC) offers guidance on ventilator allocation in
Strategies to Allocate Ventilators from Stockpiles to Facilities (March 20, 2020). CDC guidance includes needs assessment, facility capabilities to handle additional ventilators, stakeholder input, and ethical considerations.
The Department of Health and Human Services (HHS) published
Optimizing Ventilator Use during the COVID-19 Pandemic (March 31, 2020). HHS offers guidelines for use, allocation of equipment from the Strategic National Stockpile, and crisis strategies such as using one ventilator for two patients.
A
JAMA viewpoint article,
A Framework for Rationing Ventilators and Critical Care Beds During the COVID-19 Pandemic, published March 27, 2020, offers considerations for rationing should the need arise.
ECRI recommends splitting ventilators between two patients only as a last resort. If the need arises, New York-Presbyterian Hospital's
Ventilator Sharing Protocol: Dual-Patient Ventilation with a Single Mechanical Ventilator for Use during Critical Ventilator Shortages offers advice for reducing the risks.
ICU Utilization
Several models look at ICU use throughout the pandemic. In March 2020, the Institute for Health Metrics and Evaluation at the University of Washington published
Forecasting COVID-19 Impact on Hospital Bed-Days, ICU-Days, Ventilator Days and Deaths by US State in the Next 4 Months. The group maintains updated data at
COVID-19 Estimation Updates. Their predictions for the entire United States and state-specific predictions are available at
COVID-19 Projections (scroll to "Hospital Resource Use").
A
Health Affairs analysis,
American Hospital Capacity and Projected Need for COVID-19 Patient Care, used a midlevel estimate that 40% of the U.S. population will eventually contract the virus to calculate projected capacity gaps.
NHSN Module
CDC has also introduced a
COVID-19 module, within the National Healthcare Safety Network (NHSN) patient safety component. As CDC states:
The Module enables hospitals to report daily counts of patients with suspected and confirmed COVID-19 diagnoses and current use and availability of hospital beds and mechanical ventilators. NHSN, in turn, will enable state and local health departments to gain immediate access to the COVID-19 data for hospitals in their jurisdictions. COVID-19 data submitted to NHSN also will be used by CDC's emergency COVID-19 response and by . . . HHS' COVID-19 tracking system maintained in the Office of the Assistant Secretary of Preparedness and Response.
The recommendations contained in Ask ECRI do not constitute legal advice. Facilities should consult legal counsel for specific guidance and develop clinical guidance in consultation with their clinical staff.
