This article reviews existing guidance for ICU triage decisions during a public health emergency that overwhelms available ICU capacity and proposes an algorithm intended to facilitate rapid implementation and assessment.

The authors propose a triage algorithm intended to prioritize saving the most life-years (with first-come, first-served priority as a tie-breaker), with the goal of providing practical guidance that is easy to implement and to follow. The authors recommend priority based on a combined scoring system that incorporates:

• Performance score (e.g., Clinical Frailty Score)
• ASA score (assessment of patient’s overall health)
• Number of organ failures (e.g., using SOFA score)
• Predicted survival.

This factors are incorporated into a number of guidance documents in various combinations and with varying weight. Existing protocols typically prioritize based on either one or a combination of:

• Medical benefit
• First-come, first-served
• Saving the most lives
• Saving the most life-years.

The authors recommend using life-years saved as a tiebreaker for similarly scored patients. Notably, advocates for persons with disabilities and older persons often argue that this approach disadvantages those communities, potentially in violation of existing U.S. anti-discrimination laws. The authors also suggest a first-come, first-served approach (rather than random allocation, such as a lottery) as a tiebreaker on the basis that clinicians’ relative unfamiliarity with random allocation may result in the loss of valuable time. Other guidance recommends random allocation system to avoid disadvantaging patients who lack resources such as transportation that may delay seeking care or patients who become ill later due to conformity with suggested or mandatory prophylactic measures.