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Abstract：
BACKGROUND: At the height of the COVID-19 pandemic, Thailand had almost depleted its critical care resources, particularly intensive care unit (ICU) beds and ventilators. This prompted the necessity to develop a national guideline for resource allocation. This paper describes the development process of a national guideline for critical resource allocation in Thailand during the COVID-19 pandemic.
METHODS: The guideline development process consisted of three steps: (1) rapid review of existing rationing guidelines and literature; (2) interviews of Thai clinicians experienced in caring for COVID-19 cases; and (3) multi-stakeholder consultations. At steps 1 and 2, data was synthesized and categorized using a thematic and content analysis approach, and this guided the formulation of the draft guideline. Within step 3, the draft Thai critical care allocation guideline was debated and finalized before entering the policy-decision stage.
RESULTS: Three-order prioritization criteria consisting of (1) clinical prognosis using four tools (Charlson Comorbidity Index, Sequential Organ Failure Assessment, frailty assessment and cognitive impairment assessment), (2) number of life-years saved and (3) social usefulness were proposed by the research team based on literature reviews and interviews. At consultations, stakeholders rejected using life-years as a criterion due to potential age and gender discrimination, as well as social utility due to a concern it would foster public distrust, as this judgement can be arbitrary. It was agreed that the attending physician is required to be the decision-maker in the Thai medico-legal context, while a patient review committee would play an advisory role. Allocation decisions are to be documented for transparency, and no appealing mechanism is to be applied. This guideline will be triggered only when demand exceeds supply after the utmost efforts to mobilize surge capacity. Once implemented, it is applicable to all patients, COVID-19 and non-COVID-19, requiring critical care resources prior to ICU admission and during ICU stay.
CONCLUSIONS: The guideline development process for the allocation of critical care resources in the context of the COVID-19 outbreak in Thailand was informed by scientific evidence, medico-legal context, existing norms and societal values to reduce risk of public distrust given the sensitive nature of the issue and ethical dilemmas of the guiding principle, though it was conducted at record speed. Our lessons can provide an insight for the development of similar prioritization guidelines, especially in other low- and middle-income countries.
METHODS: The guideline development process consisted of three steps: (1) rapid review of existing rationing guidelines and literature; (2) interviews of Thai clinicians experienced in caring for COVID-19 cases; and (3) multi-stakeholder consultations. At steps 1 and 2, data was synthesized and categorized using a thematic and content analysis approach, and this guided the formulation of the draft guideline. Within step 3, the draft Thai critical care allocation guideline was debated and finalized before entering the policy-decision stage.
RESULTS: Three-order prioritization criteria consisting of (1) clinical prognosis using four tools (Charlson Comorbidity Index, Sequential Organ Failure Assessment, frailty assessment and cognitive impairment assessment), (2) number of life-years saved and (3) social usefulness were proposed by the research team based on literature reviews and interviews. At consultations, stakeholders rejected using life-years as a criterion due to potential age and gender discrimination, as well as social utility due to a concern it would foster public distrust, as this judgement can be arbitrary. It was agreed that the attending physician is required to be the decision-maker in the Thai medico-legal context, while a patient review committee would play an advisory role. Allocation decisions are to be documented for transparency, and no appealing mechanism is to be applied. This guideline will be triggered only when demand exceeds supply after the utmost efforts to mobilize surge capacity. Once implemented, it is applicable to all patients, COVID-19 and non-COVID-19, requiring critical care resources prior to ICU admission and during ICU stay.
CONCLUSIONS: The guideline development process for the allocation of critical care resources in the context of the COVID-19 outbreak in Thailand was informed by scientific evidence, medico-legal context, existing norms and societal values to reduce risk of public distrust given the sensitive nature of the issue and ethical dilemmas of the guiding principle, though it was conducted at record speed. Our lessons can provide an insight for the development of similar prioritization guidelines, especially in other low- and middle-income countries.
摘要：
背景：在COVID-19大流行的高峰期，泰国几乎耗尽了重症监护资源，特别是重症监护病房（ICU）的病床和呼吸机。这促使有必要制定国家资源分配准则。本文介绍了COVID-19大流行期间泰国关键资源分配国家指南的制定过程。
方法：指南制定过程包括三个步骤：（1）快速审查现有的配给指南和文献；（2）采访在照顾COVID-19病例方面经验丰富的泰国临床医生；（3）多方利益相关者协商。在步骤1和2，使用主题和内容分析方法对数据进行了综合和分类，这指导了准则草案的制定。在第3步中，在进入决策阶段之前，对泰国重症监护分配指南草案进行了辩论并最终确定。
结果：三阶优先标准，包括（1）使用四种工具的临床预后（Charlson合并症指数，序贯器官失效评估，虚弱评估和认知障碍评估)，（2）研究小组根据文献综述和访谈提出了保存生命年数和（3）社会有用性。在协商中,由于潜在的年龄和性别歧视，利益相关者拒绝使用生命年作为标准，以及社会效用，因为担心它会助长公众的不信任，因为这个判断可以是任意的。商定，主治医师必须是泰国医学法律背景下的决策者，而患者审查委员会将发挥咨询作用。分配决策要记录在案，以提高透明度，没有上诉机制。只有在尽最大努力调动激增能力后，需求超过供应时，才会触发该准则。一旦实施，它适用于所有患者，COVID-19和非COVID-19，在入住ICU之前和入住ICU期间需要重症监护资源。
结论：在泰国COVID-19爆发的背景下，重症监护资源分配的指南制定过程是有科学证据的，医学法律背景，考虑到问题的敏感性和指导原则的道德困境，现有的规范和社会价值观可以减少公众不信任的风险，尽管它以创纪录的速度进行。我们的经验教训可以为制定类似的优先级指南提供见解，特别是在其他低收入和中等收入国家。
方法：指南制定过程包括三个步骤：（1）快速审查现有的配给指南和文献；（2）采访在照顾COVID-19病例方面经验丰富的泰国临床医生；（3）多方利益相关者协商。在步骤1和2，使用主题和内容分析方法对数据进行了综合和分类，这指导了准则草案的制定。在第3步中，在进入决策阶段之前，对泰国重症监护分配指南草案进行了辩论并最终确定。
结果：三阶优先标准，包括（1）使用四种工具的临床预后（Charlson合并症指数，序贯器官失效评估，虚弱评估和认知障碍评估)，（2）研究小组根据文献综述和访谈提出了保存生命年数和（3）社会有用性。在协商中,由于潜在的年龄和性别歧视，利益相关者拒绝使用生命年作为标准，以及社会效用，因为担心它会助长公众的不信任，因为这个判断可以是任意的。商定，主治医师必须是泰国医学法律背景下的决策者，而患者审查委员会将发挥咨询作用。分配决策要记录在案，以提高透明度，没有上诉机制。只有在尽最大努力调动激增能力后，需求超过供应时，才会触发该准则。一旦实施，它适用于所有患者，COVID-19和非COVID-19，在入住ICU之前和入住ICU期间需要重症监护资源。
结论：在泰国COVID-19爆发的背景下，重症监护资源分配的指南制定过程是有科学证据的，医学法律背景，考虑到问题的敏感性和指导原则的道德困境，现有的规范和社会价值观可以减少公众不信任的风险，尽管它以创纪录的速度进行。我们的经验教训可以为制定类似的优先级指南提供见解，特别是在其他低收入和中等收入国家。
