This article reports on the California Department of Public Health’s newly released guidelines for allocating scarce resources if necessary due to case surge related to COVID-19.

The guidance includes discussion of:

• Continuum of care (conventional, contingency, crisis);
• Roles and responsibilities;
• Planning and implementation; and
• Response, including triage, ethical considerations, and surge capacity.

California’s new guidelines, like those of many other states, prioritize patients for resources based on their likelihood of survival with treatment. Allocations decisions should be made by a group of qualified triage officers, rather than bedside care team members. Allocation is based on a combined score incorporating the patient’s sequential organ failure assessment (SOFA) score and additional score reflecting the presence on major comorbidities affecting long-term prognosis or severely life-limiting conditions with death likely within one year.

Based on the life-cycle principle (prioritizing the lives of those who have had less opportunity to live through life’s stages), the California guidelines prioritize younger patients in the event of a tie in the allocation priority score, suggesting categories of 12-40, 41-60, 61-75, and over 75 years. Critical health care workforce may also receive priority depending on the circumstances of the emergency.

The plan explicitly cites Crisis Standards of Care reports developed by the IOM (now part of the National Academies) as a template and framework, including the five basic requirements for triage decisions (fairness/equity, transparency, consistency, proportionality, accountability) and four ethical principles for resource allocation (duty to implement distributive justice, duty to care, duty to plan, duty to transparency). The full guidance document is available here.