Alberta has revised its triage strategy, which physicians must use to determine who receives life-saving treatment if intensive-care units can’t provide for all patients, to ensure children are not denied critical care.
Alberta Health Services’ original triage plan included children in the second phase, and a handful of pediatricians condemned the framework because it could require them to leave some children without care if the pandemic placed too much strain on resources. AHS last week informed staff it changed the formula so that it now excludes those younger than 18 years old.
Intensive-care units in Alberta and Saskatchewan are overwhelmed with patients infected with the coronavirus, and doctors in both systems fear they may have to decide who has a chance at living if the situation continues to deteriorate. The provinces have expanded their critical-care capacity by cancelling operations – including all organ donations in Saskatchewan – and adding makeshift ICU beds. Neither province has triggered their triage plans, although health care professionals argue the standard of care has slipped under the pressure.
Francois Belanger and Laura McDougall, two physicians with senior leadership roles at AHS, highlighted the change to Alberta’s emergency strategy in an e-mail to staff on Friday. “The executive leadership team has decided not to activate pediatric triage should AHS reach the point of activating the critical care triage protocol,” the pair wrote.
AHS spokesman Kerry Williamson confirmed the revision.
“This decision was made following ongoing discussions with our pediatric teams, who expressed understandable distress at potentially having to use pediatric triage,” he said in a statement. “Any gain in ICU capacity from pediatric triage would be negligible.”
Alberta’s triage plan will take effect should occupancy in its ICUs exceed 90 per cent. Only patients with a greater-than-20-per-cent probability of living would receive care at this stage. Phase 2 of the triage plan would begin if ICU occupancy hits 95 per cent. Then, only adults with a 50-per-cent probability of surviving would receive critical care. Under the original plan, children could have been triaged in this phase.
Samina Ali, a pediatric emergency physician at Stollery Children’s Hospital in Edmonton, was among the doctors who decried AHS’s original decision to ration critical care for children. AHS’s policy shift flew under the radar, Dr. Ali said.
“It should be celebrated,” she said. “It is absolutely the right decision.”
However, Dr. Ali considers it a complicated victory. “These children still have parents and other loved ones who will be subject to triage protocol,” she said. “I wish we could spare all of our adult loved ones.”
Alberta’s ICUs were at 78-per-cent capacity on Tuesday morning, according to Verna Yiu, AHS’s chief executive officer. When the temporary ICU beds were excluded, capacity rang in at 172 per cent.
“I’m a little more optimistic than I’ve been in quite a while,” Dr. Yiu told reporters on Tuesday. While this occupancy rate is an improvement over recent weeks, she cautioned against complacency, noting it is too early to tell whether the decline will continue. Unvaccinated COVID-19 patients make up the majority of ICU admissions.
Alberta’s ability to create makeshift ICU beds, even though they are not properly staffed, borders on miraculous, according to Alex Wong, an infectious-disease physician in Regina. Saskatchewan’s decision makers, he warned, should not bank on copying Alberta’s strategy to the same extent to stave off catastrophe.
“There is very, very, very little give at this point,” Dr. Wong said, noting Saskatchewan’s ICUs are running at around 140-per-cent to 150-per-cent baseline capacity. “We just don’t have that same kind of capacity to give in our province because we’re just several times smaller than Alberta.”
In Saskatchewan, 80 patients with COVID-19 have been admitted to ICU, exceeding the province’s total baseline capacity by one. Saskatchewan has a triage framework for adults, and a separate protocol for pediatrics.
Dr. Wong believes physicians may soon have to ration life-saving measures.
“It feels almost inevitable,” Dr. Wong said.
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