PDF(Pubmed)
Abstract：
Disconcerting reports from different EU countries during the first wave of the COVID-19 pandemic demonstrated the demand for supporting decision instruments and recommendations in case tertiary triage is needed. COVID-19 patients mainly present sequentially, not parallelly, and therefore ex-post triage scenarios were expected to be more likely than ex-ante ones. Decision-makers in these scenarios may be highly susceptible to second victim and moral injury effects, so that reliable and ethically justifiable algorithms would have been needed in case of overwhelming critical cases.To gather basic information about a potential tertiary triage instrument, we designed a three-dimensional instrument developed by an expert group using the Delphi technique. The instrument focused on three parameters: 1) estimated chance of survival, 2) estimated prognosis of regaining autonomy after treatment, and 3) estimated length of stay in the ICU. To validate and test the instrument, we conducted an anonymous online survey in 5 German hospitals addressing physicians that would have been in charge of decision-making in the case of a mass infection incident. Of about 80 physicians addressed, 47 responded. They were presented with 16 fictional ICU case vignettes (including 3 doublets) which they had to score using the three parameters of the instrument.We detected a good construct validity (Cronbach\'s Alpha 0.735) and intra-reliability (p < 0.001, Cohens Kappa 0.497 to 0.574), but a low inter-reliability (p < 0.001, Cohen\'s Kappa 0.252 to 0.327) for the three parameters. The best inter-reliability was detected for the estimated length of stay in the ICU. Further analysis revealed concerns in assessing the prognosis of the potentially remaining autonomy, especially in patients with only physical impairment.In accordance with German recommendations, we concluded that single-rater triage (which might happen in stressful and highly resource-limited situations) should be avoided to ensure patient and health care provider safety. Future work should concentrate on reliable and valid group decision instruments and algorithms and question whether the chance of survival as a single triage parameter should be complemented with other parameters, such as the estimated length of stay in the ICU.
摘要：
在第一波COVID-19大流行期间，来自不同欧盟国家的令人不安的报告表明，在需要进行三级分诊的情况下，需要支持决策工具和建议。COVID-19患者主要依次出现，不是平行的，因此，预计事后分流方案比事前分流方案更有可能。在这些情况下，决策者可能极易受到第二受害者和道德伤害的影响，因此，在压倒性的关键案例中，需要可靠和道德上合理的算法。要收集有关潜在三级分诊仪的基本信息，我们使用Delphi技术设计了由专家组开发的三维仪器。该仪器集中在三个参数上：1）估计的生存机会，2）治疗后恢复自主性的估计预后，和3)估计在ICU的住院时间。要验证和测试仪器，我们在5家德国医院进行了一项匿名在线调查,调查对象是在发生大规模感染事件时负责决策的医生.在大约80名医生中，47回答向他们展示了16个虚构的ICU病例小插曲（包括3个双曲），他们必须使用仪器的三个参数进行评分。我们检测到良好的结构效度（Cronbach'sAlpha0.735）和内部可靠性（p<0.001，CohensKappa0.497至0.574），但三个参数的间可靠性较低(p<0.001，科恩的Kappa为0.252至0.327)。对于估计的ICU住院时间，检测到最佳的相互可靠性。进一步的分析揭示了在评估潜在剩余自主权的预后方面的担忧，尤其是只有身体损伤的患者。根据德国的建议，我们得出的结论是,应避免单一评级患者分诊(这可能发生在压力大和资源高度有限的情况下),以确保患者和卫生保健提供者的安全.未来的工作应该集中在可靠和有效的群体决策工具和算法，并质疑生存的机会作为一个单一的分类参数是否应该补充其他参数，例如在ICU的估计停留时间。
