Burkle, Frederick

Critical Care

Harvard University - DASH

 The triage dilemma: opening Pandora's box... ever so slowly  (Article begins on next page)The Harvard community has made this article openly available.Please share how this access benefits you. Your story matters.Citation Burkle, Frederick M. 2010. The triage dilemma: opening Pandora'sbox.. ever so slowly. Critical Care 14(1): 401.Published Version doi:10.1186/cc8215Accessed February 19, 2015 8:16:48 AM ESTCitable Link http://nrs.harvard.edu/urn-3:HUL.InstRepos:10482818Terms of Use This article was downloaded from Harvard University's DASHrepository, and is made available under the terms and conditionsapplicable to Other Posted Material, as set forth athttp://nrs.harvard.edu/urn-3:HUL.InstRepos:dash.current.terms-of-use#LAAI applaud the eﬀ  orts by Michael Christian and colleagues [1] in taking on the diﬃ   cult dilemmas surrounding triage management and training tied to surge capacity and resource allocation within intensive care settings during pandemics. Studies on triage protocols arose primarily from critical care professionals awakened to those respon  sibilities during severe acute respiratory syndrome and then re-challenged during the current H1N1 pandemic [2-4].In reality, intensive care units with their professional staﬀ   and high-tech equipment represent a major limiting factor for most communities. Th   e most plausible scenario for a viral pathogen of greater severity and lethality is that emergency departments and hospital wards will be deluged with critical care patients, the challenge being how to provide ‘opportunities for survival’ by transferring some semblance of critical care services and expertise to these ‘non-critical care’ settings. Discipline-directed triage management protocols will only be as important as the manner in which these tertiary level algorithms can be integrated into a larger system-wide triage scheme that begins at the primary triage care level and ends with whatever additional resources a regional support system can mobilize. Many ‘uncomfortable but real’ decisions that have not, to date, been operationalized at the local level will be made.Triage management requires an infrastructure, such as health emergency operations centers (HEOCs), where central triage committees, operationalized ethical resources, palliative care guidance, data collection and analysis, and communication capacities provide high-level situational awareness for simultaneously initiating triage and modifying protocols at all health facilities and their individual triage teams [5]. While attempts to provide independent hospital-centric plans are noble, they do not solve what ultimately requires an integrated population-based system-wide solution [6].Triage is an imperfect but necessary ‘art and science’ whether based on good clinical judgment or informed by protocols that attempt to direct resources to those most likely to beneﬁ  t. Critical care studies opened Pandora’s box. What follows requires much more input from other disciplines and society itself. Although it may ﬁ  rst seem like one is trespassing professional boundaries, the investment in integrated preparedness and eﬀ  ective surge strategies, including system-wide triage, is crucial to minimize the need for rationing at all levels of care.Competing interestsThe author declares that he has no competing interests.Published: 19 January 2010References1.  Christian MD, Hamielec C, Lazar NM, Wax RS, Griffi   th L, Herridge MS, Lee D, Cook DJ: A retrospective cohort pilot study to evaluate a triage tool for use in a pandemic. Crit Care 2009, 13:R170.2.  Christian MD, Hawryluck L, Wax RS, Cook T, Lazar NM, Herridge MS, Muller MP, Gowans DR, Fortier W, Burkle FM: Development of a triage protocol for critical care during an infl  uenza pandemic. CMAJ 2006, 175:1377-1381.3.  Kumar A, Zarychanski R, Pinto R, Cook DJ, Marshall J, Lacroix J, Stelfox T, Bagshaw S, Choong K, Lamontagne F, Turgeon AF, Lapinsky S, Ahern SP, Smith O, Siddiqui F, Jouvet P, Khwaja K, McIntyre L, Menon K, Hutchison J, Hornstein D, Joff  e A, Lauzier F, Singh J, Karachi T, Wiebe K, Olafson K, Ramsey C, Sharma S, Dodek P; Canadian Critical Care Trials Group H1N1 Collaborative: Critically ill patients with 2009 infl  uenza A (H1N1) infection in Canada. JAMA 2009, 302:1872-1879.4.  Devereaux AV, Dichter JR, Christian MD, Dubler NN, Sandrock CE, Hick JL, Powell T, Geiling JA, Amundson DE, Baudendistel TE, Braner DA, Klein MA, Berkowitz KA, Curtis JR, Rubinson L; Task Force for Mass Critical Care: Defi  nitive care for the critically ill during a disaster: a framework for allocation of scarce resources in mass critical care. Task Force for Mass Critical Care. Chest 2008, 133 (5 Suppl):51S-66S.5.  Burkle FM Jr., Hsu EB, Loehr M, Christian MD, Markenson D, Rubinson L, Archer FL: Defi  nition and functions of health unifi  ed command and emergency operations centers for large-scale bioevent disasters within the existing ICS. Disaster Med Public Health Prep 2007, 1:135-141.6.  Frolic A, Kata A, Kraus P: Development of a critical care triage protocol for pandemic infl  uenza: integrating ethics, evidence and eff  ectiveness. Healthc Q 2009, 12:56-64.© 2010 BioMed Central LtdThe triage dilemma: opening Pandora’s box… ever so slowlyFrederick M Burkle, Jr*See related research by Christian et al., http://ccforum.com/content/13/5/R170LETTER*Correspondence: fburkle@hsph.harvard.edu Harvard Humanitarian Initiative, Harvard School of Public Health, 14 Story Street, 2nd Floor, Cambridge, MA 02138, USABurkle Critical Care 2010, 14:401 http://ccforum.com/content/14/1/401doi:10.1186/cc8125Cite this article as: Burkle Jr FM: The triage dilemma: opening Pandora’s box… ever so slowly. Critical Care 2010, 14:401.© 2010 BioMed Central Ltd

The triage dilemma: opening Pandora's box... ever so slowly

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The triage dilemma: opening Pandora's box... ever so slowly

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