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.
■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。