COVID-19: Expert Review of Relevant and Emerging Literature

COVID-19: Expert Reviews of Relevant and Emerging Literature2020-07-14T17:37:26-04:00

This research letter discusses a study that employed universal COVID testing of previously untested nursing home residents across 11 Maryland long-term care facilities.

  • Untested residents were asymptomatic.
  • This study identified an additional 354 cases of positive SARS-CoV-2 infection(39.6% of residents tested) . This is compared to the original 153 cases identified via targeted symptom-based testing.
  • Solely utilizing symptom-based testing may miss a substantial number of asymptomatic residents who can perpetuate transmission in long-term care facilities.
  • COVID outbreaks and mortality in long term care facilities may be lowered by increased testing and case detection.

Bigelow BF, Tang O, Barshick B. Outcomes of Universal COVID-19 Testing Following Detection of Incident Cases in 11 Long-term Care Facilities.  JAMA Intern Med. Published online July 14, 2020. doi: 10.1001/jamainternmed.2020.3738

Summary authored by Daniel Chimitt with edits by Jennifer Carnahan, MD, MPH, MA

This article examines the COVID-19 preparedness of fifty-six nursing homes across the United States.

  • 56 of 942 nursing homes surveyed responded to this survey
  • The greatest preparedness concerns of the 56 nursing homes in this study were: lack of supplies (43%), staff shortages (34%), and resident health and safety (14%).
  • The financial burden of the pandemic on nursing homes is immense. Increased cost of supplies has led to inadequate supply of PPE and staff shortages have resulted in increased overtime.

Quigley DD, Dick A, Agarwal M, et al. COVID ‐19 Preparedness in Nursing Homes in the Midst of the Pandemic. Journal of the American Geriatrics Society. Published online April 28, 2020. doi: 10.1111/jgs.16520

Summary authored by Daniel Chimitt with edits by Jennifer Carnahan, MD, MPH, MA

Published on :  | By Megan McHenry

Weekly Review: Clinical testing and treatment

Clinical Testing and Evaluations

In a cohort of 145 patients with mild to moderate COVID-19 illness, replication of SARS-CoV-2 in older children led to similar levels of viral RNA as adults, but significantly greater amounts are detected in children younger than 5 years. While the study only looked at nucleic acid levels rather than infectious virus, it draws concerns that young children could potentially be important drivers of SARS-CoV-2 spread in the population.
In a study of 85 COVID+ patients, SARS-CoV-2 RNA in serum (which generally has lower levels that the corresponding viral loads of throat swabs) was detected at highest levels between 11-15 days after symptom onset. The extent of lab derangement was higher and end organ damage was more common in those with higher SAR-CoV-2 RNA serum levels compared to those with lower levels. Mortality rates were also higher among patients with RNAemia.

Treatment

In a comparative analysis of phase 3 data from a remdesivir trial and a retrospective cohort of patients with severe COVID-19 found that remdesivir was associated with significantly greater clinical recovery by day 14 and 62% reduced odds of death versus standard-of-care treatment in patients with severe COVID-19

Observational study of 255 patients w/ COVID-19 found when IL-6 receptor inhibitors (tocilizumab or sarilumab) was administered prior to >45%FiO2 requirements, there was an associated with improved COVID-19 outcomes, such as decreased intubation and reduced mortality.

A retrospective study looking at hospitalized patients with COVID-19 who were admitted to the ICU compared to those not admitted to the ICU, and the clinical data regarding use of tocilizumab (an IL-6 inhibitor) was compared. The ICU group had higher rates of preexisting co-morbidities (hypertension, diabetes, coronary disease, etc) and higher IL‐6 than non- ICU group (all P<0.05). Age, peak IL‐6, and peak d‐dimer were significant predictors of in‐hospital mortality (1.05 [1.01‐1.09], P=0.012, 1.001 [1.000‐1.002], P=0.002, 1.10 [1.03‐1.18], P=0.008). Tocilizumab did not affect in‐hospital mortality after adjustment for confounders including IL‐6 (OR [95% CI]: 1.00 [0.27‐3.72, P=0.998]).

This article describes some of the issues that older adults may face during the transition from the emergency phase to “phase 2” of the COVID-19 pandemic. It is written with regards to older adults in general and then discusses the implications on patients with dementia.

  • Most countries are beginning to reopen or shift into “phase 2” of the pandemic. This creates new challenges that will disproportionately impact the older adult population.
  • Social distancing and self-isolation policies have negatively impacted the health of older adults. This has taken form through missing scheduled clinical visits, social isolation, and increased sedentary lifestyle.
  • People with dementia have been affected by social distancing and isolation which can lead to worse pre-existing neuropsychiatric symptoms such as agitation, depression, and feelings of loneliness or abandonment.
  • Loss of nonpharmacological therapy for patients with dementia due to the pandemic may result in new or increasing dosages of psychoactive drugs, thereby causing undesired side effects.
  • As “phase 2” rolls out, it will be necessary to prioritize resources for those who need them. Patients with dementia can be given a brief triage questionnaire focused on biopsychosocial status in order to determine those with the greatest need for immediate care.
  • Remote care delivery strategies are often advantageous for older adults and especially those with dementia. We should continue to develop these systems and ensure that vulnerable populations have proper access to them.

Canevelli M, Bruno G, Cesari M. Providing Simultaneous COVID-19–sensitive and Dementia-Sensitive Care as We Transition from Crisis Care to Ongoing Care. J Am Med Dir Assoc. Published online May 21, 2020. doi:10.1016/j.jamda.2020.05.025

Summary authored by Daniel Chimitt with edits by Jennifer Carnahan, MD, MPH, MA

This commentary outlines challenges assisted living communities face in light of COVID-19 and provides recommendations for adhering to federal guidelines in spite of these challenges.

Assisted living providers face numerous challenges concerning federal guidelines to prevent the spread of COVID-19. Among them include family visitation restrictions, transfer policies, use of third-party providers as essential workers, staffing guidelines, and rural hospitalizations. To address all of these challenges, the authors recommend effective communication practices by assisted living providers that incorporates digital technology. Different forms of online communication can be used with families, government agencies, and other providers. Because of the unique structure and needs of assisted living communities, assisted living providers need to work alongside state and federal agencies to care for and reduce the number of people with COVID-19.

Published on :  | By Daniel Orenstein

Ethics, Law & Policy Roundup: Staff, Stuff, Space & Systems

Facilities and Staff

This Viewpoint by Guddati argues that facility policies that fail to provide adequate PPE for health care professionals, including those that prohibit using scarce PPE (specifically masks) when seeing patients not confirmed to be positive for COVID-19, are improper medically, ethically, and legally. The author describes a scenario in which a physician is prohibited from wearing a mask while seeing patients in a COVID-19 rule-out floor. Medically, the author argues, this is inappropriate because the floor has higher probability of having infected patients, posing higher risk to health care professionals and their families and increasing personnel shortages. Ethically, a duty to treat (distinct and broader than legal duty) requires health care professionals to provide care even at increased personal risk, but also requires reciprocal actions from facilities to balance patient care and personnel safety. Legally, the author cites to employer duties under Occupational Safety and Health Administration (OSHA) guidelines to provide a safe work environment. OSHA has issued guidance for employers regarding COVID-19, including specifically for health care that allow for flexibility to account for PPE scarcity, including prioritizing PPE for higher-risk exposure situations. However, OSHA’s guidance does not eliminate an employer’s duty to provide a safe work environment, which is also frequently required under parallel state laws.

This article by Giangola et al. describes the approach taken by a New York medical center to increase capacity and provide intensive care during a surge of COVID-19 cases in March-April 2020. Among the strategies discussed is adaptation of the tiered staffing strategy provided by the Society of Critical Care Medicine as a staffing model for ICUs. Teams consisting of ICU physicians, non-ICU physicians, residents, Pas, and nursing staff were deployed, leveraging the competence of physician extenders and allowing rapid expansion of physical capabilities. Scheduling was designed to maximize contiguous days in-house and days off to prevent burnout. These approaches allowed utilization of surgeons as medical intensivists and rapid training of noncritical care-certified surgeons to manage COVID-19 patients with supervision.

This Health Affairs blog by Madad et al. discusses challenges in procuring equipment and supplies, protecting health care workforce, and adapting to changing supply chains and complexities of operationalizing crisis capacity strategies in another large New York health system. System-wide guidance was provided on extending and reusing PPE, video and photo guides were developed to adapt to different ventilator models, protocols were created to decrease the amount of medications requiring IV infusion pumps, and a central network was utilized to coordinate and source equipment and PPE from non-traditional sources. Among other strategies, training videos, guidance documents, tip sheets, pictorial guides, and a hotline helped train and re-train health care workers on infection prevention and PPE donning and doffing as public health guidance evolved.

Resource Allocation

This article by Iyer et al. discusses resource allocation in the context of enrollment in COVID-19 treatment trials. Specifically, the article addresses how to determine who should be enrolled when there are more interested and eligible patients than trial slots and the importance of avoiding ad hoc and potentially biased decision-making, which in addition to ethically problems could also compromise the value of the trial. The article notes that trials more often face the challenge of sufficient recruitment, but allocation of limited trial slots has arisen in the context of experimental treatments for conditions with limited therapeutic alternatives, such as AZT trials during the early HIV epidemic. The article argues that at least four ethical principles are relevant: social value, fair participant selection, risk-benefit profile, and collaborative partnership. Based on these, the article recommends using a weighted lottery system to select participants. A random lottery enhances fairness of selection and stewardship of resources, but does not optimize risk-benefit profiles or social value, but appropriate weighting (e.g., algorithmically ensuring proportionate representation of persons with clinically relevant comorbidities) can expand the advantages of a lottery system to ethically allocate resources and enhance the social value of trials.

This article is the American Geriatrics Society (AGS) position statement, “Resource Allocation Strategies and Age-Related Considerations in the COVID-19 Era and Beyond”. It includes the official recommendations of AGS, designed to guide stakeholders in the allocation of resources during the COVID-19 pandemic.

  1. Age should not be a factor in resource allocation nor should it be used to exclude patients from standard of care interventions.
  2. Social determinants of health should be regarded during the assessment of comorbidities.
  3. When there is a need for allocation of limited supplies key factors to consider are in-hospital survival and comorbidities contributing to short-term mortality.
  4. Criteria including “life-years saved” and “long-term predicted life expectancy” create bias and should not be considered in regard to resource allocation.
  5. Individuals charged with triage should have knowledge of available resources and be available to clinicians during the decision-making process of resource allocation; however, they should not be involved in the care of patients needing the limited resources. If feasible triage committees should be multidisciplinary.
  6. Resource allocation plans should be transparent and administered consistently. These plans should be created with guidance from ethics, medicine, law, and nursing. Reassessment of plans should be at regular intervals to include current scientific developments and to evaluate impact and potential bias.
  7. Advance care planning discussions play a crucial role in delivery of ethical patient centered care. While these discussions would ideally occur in advance of a crisis, attempts to conduct advance care planning in all settings should be escalated.

This article is a companion article to the American Geriatrics Society (AGS) position statement, “Resource Allocation Strategies and Age-Related Considerations in the COVID-19 Era and Beyond”. It describes the legal and ethical background for the position statement and seeks to inform hospitals, health systems, and policy makers about ethical considerations for the allocation of resources to older adults during an emergency.

  • Health care workers need just frameworks from policy makers to help guide decisions about resource allocation during the pandemic.
  • Using age alone as an exclusion factor for certain types of treatment such as ventilators or ICU care ignores many other indicators of overall health such as functional status, cognitive status, or pre-existing conditions.
  • Strategies that use age as a primary factor to inform resource allocation disproportionately impact older adults and impose a greater risk of disparate impacts on racial and ethnic minorities who are being disproportionately affected by COVID-19.
  • There are frameworks that do not take age into account such as the SOFA score or the multi-principal allocation framework endorsed by the Commonwealth of Pennsylvania.
  • Age or potentially saved life-years could be used as a “tiebreaker” or secondary factor in allocation of resources.
  • Greater emphasis should be placed on having advance care planning completed for older adults before they are in crisis but these conversations should not be confused with resource allocation or subtly hint or coerce patients into considering the need for resource conservation.

Summary authored by Daniel Chimitt with edits by Jennifer Carnahan, MD, MPH, MA

This article identifies the characteristics of COVID-19 related deaths in a sample population from Italy, describing the clinical course and phenotype of these COVID-19 related deaths in the hospital of young adults (age < 65) as compared to older adults (age ≥ 65).

Introduction

It is well documented that the mortality rate of COVID-19 is greater in older adults and, more generally, in patients with pre-existing conditions. This study examines a sample population from the national surveillance system established by the Italian National Institute of Health to collect information on people diagnosed with COVID-19. Univariate, bivariate, and simple statistics were used to describe the results.

Study Population

  • As of May 21, 2020, there were 31,096 COVID-19 related deaths documented and reported in Italy.

This study includes 3,032 patients who died in the hospital with COVID-19 in Italy (9.8% of COVID-19 related deaths at that time) and were selected to be representative of the overall population.

  • COVID-19 related deaths in this study were defined as those who tested positive for SARS-CoV-2 through rtPCR, independent of pre-existing conditions that may have caused or contributed to deaths.
  • Of the 3,032 patients included, 368 (12.1%) were aged < 65 (range 5-64) and 2,664 were aged ≥ 65 (range 6-105).

Results-Comorbidities

  • Older adults (≥ 65) with COVID-19 who died in the hospital had a higher number of comorbidities. Common comorbidities across all age groups were hypertension, diabetes, and ischemic heart disease.
  • Common comorbidities in the older group were: ischemic heart disease, atrial fibrillation, heart failure, stroke, hypertension, dementia, COPD, and chronic renal.
  • Common comorbidities in the younger group were: obesity, chronic liver disease, and HIV infection.
  • 9% of younger adults (< 65) had no pre-existing comorbidities compared to 3.2% of older adults (≥ 65), suggesting that healthy adults can still develop COVID-19 related complications that may lead to death.

Results-symptoms, diagnoses, and hospital course

  • The most common symptoms for all ages were fever and dyspnea and Acute Respiratory Distress Syndrome (ARDS) was diagnosed in a majority of patients.
  • Diarrhea was more common in younger adults (< 65) and non respiratory complications were a more common sequelae (cardiac, renal, and superinfection).
  • Younger adults received more antiviral and steroidal treatments than older adults (≥ 65).
  • Older adults had a shorter time from symptom onset to COVID-19 testing, and to hospitalization and a shorter time from hospital admission to death.

Palmieri L, Vanacore N, Donfrancesco C, et al. Clinical Characteristics of Hospitalized Individuals Dying with COVID-19 by Age Group in Italy. The Journals of Gerontology. Published online June 7, 2020. doi: 10.1093/gerona/glaa146

Summary authored by Daniel Chimitt with editing by Dr. Jennifer Carnahan

This public radio story provides tips for deciphering between accurate and inaccurate information on social media.

During this public radio news story, a representative from the News Literacy Project shared the tools created for students to evaluate news stories circulating on social media platforms. Because misinformation can spread rapidly, it is important to recognize misinformation and know that messages have been designed to not only reinforce someone’s beliefs but to exploit them. This misinformation spreads quickly because people trust their friends more than the media or government so when misinformation is shared by a friend, it is easier to believe that it must be true because people think of their friends as credible sources. It is recommended to learn to separate scrolling from intentional news consumption. Slowing down and checking to see if claims are backed by evidence from other reputable outlets can reduce the tendency to simply believe that well-produced looking material is credible.

This article suggests that federal and state government as well as long-term care facilities should ensure meaningful communication in care settings to reduce negative mental health effects stemming from the COVID-19 pandemic.

Older adults in long-term care facilities are at greater risk for severe consequences from COVID-19, and family caregivers are the most trusted allies for those residents. With recent federal guidelines restricting family visitation, residents have experienced even greater isolation. The authors argue that even with the lack of allowable physical visitation, government officials and facility administrators should work to ensure ongoing family communication and engagement. They recommend specific actions to enable this meaningful communication including strengthening nursing home-family caregiver communication channels, activating family councils, mobilizing students and trainees, and encouraging family members to manage their own personal safety and health.

This letter to the editor discusses the vital role of an information specialist to assist public health information seekers during COVID-19.

Public health awareness is key to reducing the spread of COVID-19, making it the most effective tool of protection during the crisis. To combat the effects of the pandemic, the authors note the important role of information specialists and librarians in assisting with public health awareness for prevention measures, supporting researchers about the latest research and developments, and offering service to general information seekers. They determined that the channels most commonly used to facilitate public health awareness during the COVID-19 pandemic include mobile apps, artificial intelligence-based chatbots, social media platforms, online video-based lectures, and electronic academic resources. Using information specialists to disseminate information to health care workers, community members, and researchers via these information channels is vital for informing and updating stakeholders of rapidly changing information.

The authors of this paper reviewed the challenges of social isolation due to COVID-19 for community- dwelling older adults with dementia and their caregivers.

In the United States, an estimated 70% of older adults with dementia live in the community setting, while another 26% live alone . Due to disruption of home-care visits from health-care providers during COVID 19, caregivers are taking over providing care such as:  tube feeding, injections, home dialysis, colostomy, and catheter care Caregivers do not feel adequately prepared or trained to do so. Caregivers providing 20 or more hours of care weekly, are more likely to experience emotional distress, financial hardship, and physical strain.

Some ways a care taker can better take care of their own mental and physical well-being is to:

  • recognize that they need to have a support system such as family or online/phone support groups that allow them to engage in socialization
  • consider the use of family members to take care of the person with dementia, allowing for some down time.
  • take advantage of community volunteers or delivery services when in need of medication, medical supplies, and groceries .

The authors describe issues related to social isolation that impact both the caregiver and person with dementia and include:  decreased structure and routine, overwhelming housework responsibilities, need to create good hygiene practices, and finding ways to stay connected socially. Some ways to combat these issues as a caregiver respectively is to:

  • create an at home structure to include activities such as safe exercises using body weight such as chair yoga, going for a drive close to home, online art and cooking classes, and live stream religious services and musical events
  • set a home-based goals every day that people with dementia can easily assist with such as organizing closets and cleaning out the freezer
  • model good hygiene by wearing a mask and giving verbal and handwritten reminders to provide cues for practices such as washing hands frequently, for at least 20 s with soap and warm water
  • facilitate social interactions with family and friends via smartphone and computer applications such as WhatsApp and FaceTime

Loneliness and social isolation has a large impact on mental and physical well-being on both parties and should therefore not be ignored.

Greenberg, N. E., Wallick, A., & Brown, L. M. (2020, June 25). Impact of COVID-19 Pandemic Restrictions on Community-Dwelling Caregivers and Persons With Dementia. Psychological Trauma: Theory, Research, Practice, and Policy. Advance online publication. http://dx.doi.org/10.1037/tra0000793

Published on :  | By Maria Brann

Review: Talking your team through a crisis

This article provides steps for physicians to effectively communicate with their teams during the COVID-19 pandemic.

Communicating during uncertainty is an essential leadership skill, regardless of whether one is in a formal leadership position. The author provides five steps for health care providers to be effective at communicating with team members about COVID-19 and to help reduce anxiety:

  • Pause and breathe (calm yourself before communicating with others)
  • Put yourself in their shoes (think about what you would want to know if you were in their position)
  • Do your research (use credible sources to avoid misinformation)
  • Speak clearly and confidently (and be honest about what you know)
  • Have specific next steps (provide tangible action items they can take)
Published on :  | By Megan McHenry

COVID Cuts: A brief summary of this week’s COVID-19 clinical research

Vaccine Update: 

The mRNA-1273 vaccine (from Moderna and NIAID) induced anti-SARS-COV-2 immune responses (anti-Spike-2P glycoprotein antibody) in all participants and no trial-limiting safety concerns were identified.

Epidemiology:

During hospital-wide SARS-CoV-2 antibody (Ab) screening in healthcare workers (HCW) and staff in Belgium, 6.4% had IgG antibodies for SARS-CoV-2

During hospital-wide SARS-CoV-2 Ab screening in HCW and staff at Mass Gen Hospital (performed in 3 phases), 12.9% had positive results for SARS-CoV-2, and universal masking policy was associated with a significantly lower rate of SARS-CoV-2

Overall SARS-CoV-2 PCR- positivity rates of HCW in a pediatric setting in Paris was 2.3% (compared to 2.8% in an associated adult setting)

Treatment:

Within a retrospective review of critically ill adults with SARS-CoV-2 pneumonia, no difference was found between hydroxychloroquine or lopinavir/ritonavir compared to standard of care

Case Reports: 

Child with Guillain-Barre syndrome after COVID-19

Child receiving remdesivir during induction chemotherapy for newly diagnosed pediatric acute lymphoblastic leukemia with concomitant SARS-CoV-2 infection

Child with oral ulceration as an early feature of multisystem inflammatory syndrome in children (MIS-C)

Two children with COVID-19 positive PCR swab upon MIS-C presentation

Immunology:

Humoral and circulating follicular helper T cell responses in a cross-sectional adult cohort who had recovered from COVID-19 infection

Description of a rapid antibody discovery platform that isolated hundreds of human monoclonal antibodies again SARS-CoV-2 spike protein

SARS-CoV-2-specific T cell immunity in cases of COVID-19 and SARS, and uninfected controls

Impaired type I interferon activity and inflammatory responses in severe COVID-19 patients

 

Published on :  | By Daniel Orenstein

Ethics, Law & Policy Roundup: Staff, Stuff, Space & Systems

Facilities & Providers

In response to case surge in Arizona, hospitals in the state requested waiver of several legal requirements that generally protect patients against abuse, neglect, and discrimination, as detailed in this Arizona Republic article. The state health department responded by waiving 16 of the 35 provisions highlighted by the hospital association. Among the requirements waived were mandates that hospitals post patient rights language in all facilities, provide written patient rights statements upon admission, and provide privacy during communications with social services. Among the provisions the state declined to waive were those requiring hospitals to provide emergency services to all individuals who request them, to ensure that all medical and nursing personnel are CPR qualified within 30 days of start date, and rules governing patient transfers.

This Acta Biomedica article by Capolongo et al. proposes 10 strategies for new hospitals and refurbishment of existing hospitals to improve resilience and ability to adapt quickly to new challenges. The authors structure the strategies in two tiers: design and operations. Design strategies discussed are: Strategic Site Location; Typology Configuration; Flexibility; Functional program; and User-centeredness. Operations strategies discussed are: Healthcare network on the territory; Patient safety; HVAC and indoor air quality; Innovative finishing materials and furniture; and Healthcare digital innovation.

This commentary by Sharma et al. discusses particular challenges faced by health care providers in rural and underserved areas, including limited health care infrastructure, distance to advanced care, and population characteristics such as tobacco use, hypertension, obesity, and age. The authors offer guidance to address these issues using alternative ventilator strategies, novel PPE, and common therapeutic options. Alternative ventilator strategies include conversion of non-invasive ventilators and anesthesia machines. Novel PPE includes use of anesthesia masks with HEPA filters, sewing masks from sterile wrapping material from surgical instruments, and using 3-D printing to produce masks and face shields. Therapeutic options discussed include convalescent plasma and remdesivir, as well as potentially tocilizumab with appropriate IRB oversight if data supports this. The article also recommends use of clear drapes or intubation boxes for high-risk airway procedures to reduce HCW exposure, as well as expanded screening of HCWs and nursing home residents.

 

Supplies

This CNN article and this STAT article discuss challenges currently facing hospitals regarding distribution of remdesivir. According to hospitals, distribution to hotspot locations has not kept pace with the number of hospitalized patients, while other states and locations have more than they currently need. Phamaceutical manufacturer Gilead Sciences donated 940,000 vials to the U.S. government, and the administration has secured a further supply for 500,000 patients and is distributing according to states according to case data.

This AJPH article by Sinha, Burgeois & Sorger address community-level responses to shortages of PPE and other supplies to address supply chain fragility. The authors discuss local fabrication of a variety of items with emphasis on regulatory considerations, including: ventilators, vent splitters, N95 respirators, mask frames, surgical/cloth masks, nasopharyngeal swabs, PAPRs, face shields, PPE sanitizing techniques, surgical/procedure gowns, hand sanitizers, and scrubs.

 

Resource Allocation

This article by Han and Koch in Disaster Medicine and Public Health Preparedness, written by staff members of the New York State Task Force on Life and Law involved in the group’s Ventilator Allocation Guidelines Project, compares the 2007 and 2015 versions of the guidelines with emphasis on incorporation of advances in medicine and societal values.

Both versions rely on the same ethical principles (duty to care, duty to steward resources, duty to plan, distributive justice, and transparency) and apply clinical criteria to evaluate likelihood to survival in order to allocate ventilators during scarcity (applying first exclusionary criteria, then assessment using SOFA score, then periodic clinical assessments). Key changes from the 2007 to 2015 guidelines include limiting definition of survival to short-term survival (limiting impact of personal bias or quality of life assessments), restricting exclusionary criteria to those associated with immediate and near-immediate mortality that can be assessed with appropriate accuracy, and clarification on use of SOFA scores and periodic clinical assessments.

The authors also discuss recommendations released by other entities, including those specific to COVID-19, and how they compare to the New York guidelines, including rejection of exclusionary criteria.

 

This Pediatrics article by Antiel et al. (currently a peer reviewed pre-publication version) addresses whether pediatric patients should be prioritized for scarce life-saving treatments (specifically ECMO) during the COVID-19 pandemic. The article presents comments by a variety of experts in critical care, end of life care, bioethics, and health policy. Reflecting the diversity of opinion on this issue, the comments offer a variety of approaches:

  • Antiel & Curlin: 3-part rationing approach using prognosis first, followed by age as a tie-breaker, then random lottery for roughly equivalent cases
  • Persad & White: age-based prioritization for pediatric patients based on “fair innings” theories (young patients have had the least opportunity to live through all stages of life), but distinguished from general prioritization by life expectancy
  • Zhang, Clickman & Emanuel: multi-principle framework (based on the principle that any individual allocation principle will be flawed and insufficient standing alone) that incorporates pediatric prioritization as one among several factors for allocation that also considers prognosis, saving the most lives, lottery, and prospective instrumental value during a crisis.
  • Lantos: priority for pediatric patients as reflecting fairness from a life stage perspective and distinct from other prohibited discriminatory factors such as social worth, race, disability, gender, wealth, or fame.
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