PDF(Pubmed)
Abstract：
The spring 2020 surge of COVID-19 unprecedentedly strained ventilator supply in New York City, with many hospitals nearly exhausting available ventilators and subsequently seriously considering enacting crisis standards of care and implementing New York State Ventilator Allocation Guidelines (NYVAG). However, there is little evidence as to how NYVAG would perform if implemented.
To evaluate the performance and potential improvement of NYVAG during a surge of patients with respect to the length of rationing, overall mortality, and worsening health disparities.
This cohort study included intubated patients in a single health system in New York City from March through July 2020. A total of 20 000 simulations were conducted of ventilator triage (10 000 following NYVAG and 10 000 following a proposed improved NYVAG) during a crisis period, defined as the point at which the prepandemic ventilator supply was 95% utilized.
The NYVAG protocol for triage ventilators.
Comparison of observed survival rates with simulations of scenarios requiring NYVAG ventilator rationing.
The total cohort included 1671 patients; of these, 674 intubated patients (mean [SD] age, 63.7 [13.8] years; 465 male [69.9%]) were included in the crisis period, with 571 (84.7%) testing positive for COVID-19. Simulated ventilator rationing occurred for 163.9 patients over 15.0 days, 44.4% (95% CI, 38.3%-50.0%) of whom would have survived if provided a ventilator while only 34.8% (95% CI, 28.5%-40.0%) of those newly intubated patients receiving a reallocated ventilator survived. While triage categorization at the time of intubation exhibited partial prognostic differentiation, 94.8% of all ventilator rationing occurred after a time trial. Within this subset, 43.1% were intubated for 7 or more days with a favorable SOFA score that had not improved. An estimated 60.6% of these patients would have survived if sustained on a ventilator. Revising triage subcategorization, proposed improved NYVAG, would have improved this alarming ventilator allocation inefficiency (25.3% [95% CI, 22.1%-28.4%] of those selected for ventilator rationing would have survived if provided a ventilator). NYVAG ventilator rationing did not exacerbate existing health disparities.
In this cohort study of intubated patients experiencing simulated ventilator rationing during the apex of the New York City COVID-19 2020 surge, NYVAG diverted ventilators from patients with a higher chance of survival to those with a lower chance of survival. Future efforts should be focused on triage subcategorization, which improved this triage inefficiency, and ventilator rationing after a time trial, when most ventilator rationing occurred.
To evaluate the performance and potential improvement of NYVAG during a surge of patients with respect to the length of rationing, overall mortality, and worsening health disparities.
This cohort study included intubated patients in a single health system in New York City from March through July 2020. A total of 20 000 simulations were conducted of ventilator triage (10 000 following NYVAG and 10 000 following a proposed improved NYVAG) during a crisis period, defined as the point at which the prepandemic ventilator supply was 95% utilized.
The NYVAG protocol for triage ventilators.
Comparison of observed survival rates with simulations of scenarios requiring NYVAG ventilator rationing.
The total cohort included 1671 patients; of these, 674 intubated patients (mean [SD] age, 63.7 [13.8] years; 465 male [69.9%]) were included in the crisis period, with 571 (84.7%) testing positive for COVID-19. Simulated ventilator rationing occurred for 163.9 patients over 15.0 days, 44.4% (95% CI, 38.3%-50.0%) of whom would have survived if provided a ventilator while only 34.8% (95% CI, 28.5%-40.0%) of those newly intubated patients receiving a reallocated ventilator survived. While triage categorization at the time of intubation exhibited partial prognostic differentiation, 94.8% of all ventilator rationing occurred after a time trial. Within this subset, 43.1% were intubated for 7 or more days with a favorable SOFA score that had not improved. An estimated 60.6% of these patients would have survived if sustained on a ventilator. Revising triage subcategorization, proposed improved NYVAG, would have improved this alarming ventilator allocation inefficiency (25.3% [95% CI, 22.1%-28.4%] of those selected for ventilator rationing would have survived if provided a ventilator). NYVAG ventilator rationing did not exacerbate existing health disparities.
In this cohort study of intubated patients experiencing simulated ventilator rationing during the apex of the New York City COVID-19 2020 surge, NYVAG diverted ventilators from patients with a higher chance of survival to those with a lower chance of survival. Future efforts should be focused on triage subcategorization, which improved this triage inefficiency, and ventilator rationing after a time trial, when most ventilator rationing occurred.
摘要：
■2020年春季COVID-19激增，纽约市的呼吸机供应空前紧张，许多医院几乎耗尽了可用的呼吸机，随后认真考虑制定危机护理标准并实施纽约州呼吸机分配指南（NYVAG）。然而,几乎没有证据表明NYVAG如果实施会如何运作。
■为了评估NYVAG在患者激增期间的性能和潜在改善，总死亡率，和日益恶化的健康差距。
这项队列研究包括2020年3月至7月在纽约市单一卫生系统中插管的患者。在危机期间，共进行了20000次呼吸机分流模拟（NYVAG后进行10000次，而在拟议的改进NYVAG后进行10000次），定义为使用前呼吸机供应95%的点。
■用于分诊呼吸机的NYVAG协议。
■观察到的存活率与需要NYVAG呼吸机配给的模拟情景的比较。
■总队列包括1671名患者；其中，674例插管患者(平均[SD]年龄，63.7[13.8]岁；465名男性[69.9％]）被包括在危机期间，571（84.7%）的COVID-19检测呈阳性。在15.0天内，163.9名患者发生了模拟呼吸机配给，如果提供呼吸机，其中44.4％（95％CI，38.3％-50.0％）会存活，而新插管的患者中只有34.8％（95％CI，28.5％-40.0％）接受重新分配的呼吸机存活。虽然插管时的分诊分类显示出部分预后分化，所有呼吸机配给的94.8％发生在时间试验后。在这个子集内，43.1％的患者插管7天或更长时间，SOFA评分良好，但未改善。如果持续使用呼吸机，估计这些患者中有60.6％会存活。修订分诊子分类，提议改进的NYVAG，会改善这种令人震惊的呼吸机分配效率低下（如果提供呼吸机，则选择呼吸机配给的患者中有25.3％[95％CI，22.1％-28.4％]可以幸存）。NYVAG呼吸机配给并未加剧现有的健康差异。
■在这项队列研究中，在纽约市COVID-192020激增的顶点期间，插管患者经历了模拟呼吸机配给，NYVAG将呼吸机从生存机会较高的患者转移到生存机会较低的患者。未来的工作应该集中在分诊分类上，这改善了这种分类效率低下，经过时间试验后，呼吸机配给，当大多数呼吸机配给发生时。
■为了评估NYVAG在患者激增期间的性能和潜在改善，总死亡率，和日益恶化的健康差距。
这项队列研究包括2020年3月至7月在纽约市单一卫生系统中插管的患者。在危机期间，共进行了20000次呼吸机分流模拟（NYVAG后进行10000次，而在拟议的改进NYVAG后进行10000次），定义为使用前呼吸机供应95%的点。
■用于分诊呼吸机的NYVAG协议。
■观察到的存活率与需要NYVAG呼吸机配给的模拟情景的比较。
■总队列包括1671名患者；其中，674例插管患者(平均[SD]年龄，63.7[13.8]岁；465名男性[69.9％]）被包括在危机期间，571（84.7%）的COVID-19检测呈阳性。在15.0天内，163.9名患者发生了模拟呼吸机配给，如果提供呼吸机，其中44.4％（95％CI，38.3％-50.0％）会存活，而新插管的患者中只有34.8％（95％CI，28.5％-40.0％）接受重新分配的呼吸机存活。虽然插管时的分诊分类显示出部分预后分化，所有呼吸机配给的94.8％发生在时间试验后。在这个子集内，43.1％的患者插管7天或更长时间，SOFA评分良好，但未改善。如果持续使用呼吸机，估计这些患者中有60.6％会存活。修订分诊子分类，提议改进的NYVAG，会改善这种令人震惊的呼吸机分配效率低下（如果提供呼吸机，则选择呼吸机配给的患者中有25.3％[95％CI，22.1％-28.4％]可以幸存）。NYVAG呼吸机配给并未加剧现有的健康差异。
■在这项队列研究中，在纽约市COVID-192020激增的顶点期间，插管患者经历了模拟呼吸机配给，NYVAG将呼吸机从生存机会较高的患者转移到生存机会较低的患者。未来的工作应该集中在分诊分类上，这改善了这种分类效率低下，经过时间试验后，呼吸机配给，当大多数呼吸机配给发生时。
