Resource Allocation

This preprint article by Sarkar et al. assesses the performance of three severity scoring systems (SOFA, OASIS, and APACHE IVa) across race/ethnicity. While developed for other purposes, such scoring systems (in particular SOFA) are also used in many scarce resource allocation guidelines as a predictor of a patient’s likelihood of recovery, which in turn may affect priority for allocation. The analysis found that each system over-predicted mortality in all ethnic groups, but that this poor calibration was more pronounced for African American and Hispanic groups. These populations are also subject to several other existing health disparities and have suffered disproportionate morbidity and mortality during the current pandemic. As a result, there is a serious risk that any disparities in severity scoring systems would compound these inequities in situations of resource scarcity by tending to withhold crucial resources from populations that are also most severely impacted. While this article is currently a preprint (and thus has not yet gone through peer review), others have also highlighted shortcomings in these systems that may have racially disparate impacts. Such findings and argument demand serious attention and further research, given the important role these scoring systems play in existing allocation frameworks.

Facilities

This memo from the Center for Health Security at Johns Hopkins flags the issue of medical oxygen supply for attention and suggests several proactive approaches to avert shortages. The memo notes that shortages of medical oxygen are already occurring and likely to persist or worsen in coming months. This will potential affect a wide range of hospitals, other health facilities, and emergency medical transportation services, among others. The memo calls for immediate preparations nationally to mitigate risks of shortages and offers suggested solutions based on input from frontline clinicians and public health officials in multiple states that have addressed the issue to date. These approaches include:

• Adding secondary oxygen supply lines that bypass existing delivery systems, allowing additional oxygen flow without freezing vaporizers.
• Improvising warm water sprinkler systems to prevent external vaporizers from freezing.
• Using oxygen concentrators as much as possible in place of cylinders, including splitting tubing to supply two patients at once.
• Conserving oxygen by lowering required saturation thresholds.
• Fitting large H oxygen cylinders with manifolds to service multiple patients simultaneously.
• Augmenting bulk oxygen delivery and portable oxygen supply.

Additionally, the memo emphasizes the importance of making clinicians more aware of the issue, developing plans to share resources between states, relaxing regulatory enforcement related to oxygen transport, and conducting rapid research on manufacturing capacity and supply chain.