Critical decisions

University of Otago expertise has been crucial in developing a tool that is available to help clinicians around the world prioritise intensive care for COVID-19 patients.

Dr Melyssa Roy (Preventive and Social Medicine) explains that she was already researching how scarce resources should be allocated during a pandemic – in conjunction with Dr Trudy Sullivan (Preventive and Social Medicine) and Professor Paul Hansen (Economics) – before the COVID-19 pandemic struck.

Roy, who specialises in public health medicine, says: “We decided to narrow the focus and look at what was potentially going to be more immediately useful – the prioritisation of patients for ventilators during COVID-19.”

In early March, three weeks before New Zealand went into a nationwide lockdown, an expert group was convened to develop a tool to help clinicians more effectively identify COVID-19 patients most in need of, and likely to benefit from, intensive care and ventilatory support, in anticipation of demand greatly exceeding supply.

Hansen, who specialises in health sector priority-setting, already had a hand in developing software that could be readily applied to the task. In 2002, he and Franz Ombler (Computer Science) invented an online suite of tools and processes – branded 1000minds – that has been applied to a variety of health and other decision-making problems since then, including prioritising patients for elective surgery.

The expert group developed guidelines for prioritising COVID-19 patients and used the 1000minds software to create what the researchers describe as a pragmatic points system representing the consensus of a group of intensive care experts about the criteria that should be applied, and the weighting given to each criterion, for prioritising patients regarding their likely clinical benefit.

The tool, which scores patients out of 100, takes into account factors such as age and pre-existing medical conditions.

“It codifies the expert knowledge that exists within the heads of ICU professionals and records it as a tool that can be used when clinicians are under unimaginable pressure to make decisions when there are, say, 20 patients and only five beds available,” Hansen explains.

He describes the tool as a more valid, reliable and sophisticated system than anything available internationally.

Roy says that it took the expert group only about three weeks to come up with the guidelines and a workable software tool, propelled by the initial prospect of the hospital system being overwhelmed by COVID-19 patients.

Sullivan, who specialises in health economics, emphasises that the tool is for use by clinicians alongside other ethical considerations when resources are constrained and is not part of some dystopian world in which computers decide who lives and who dies.

Although not immediately needed in New Zealand, clinicians in coronavirus-ravaged Northern Italy were the first to take advantage of the free online software tool and advice from the expert group: not in prioritising intensive care, but in helping prioritise hospital admissions in the face of a shortage of general hospital beds.

The Italian version of the tool is designed to be adapted for use especially in low- and middle-income countries too.

Hansen says that the research team is continuing to refine the New Zealand tool as COVID-19 plays out, and the software technology could be readily applied to any future pandemics that force clinicians to prioritise patients for treatment.

The expert group also included, among others, Dr Craig Carr (Surgical Sciences), an intensive care specialist at Dunedin Hospital; Dr Andrew Stapleton from the intensive care unit at Hutt Hospital; and a Māori health representative, Mathew Kiore, from the Southern District Health Board. Associate Professor Neil Pickering (Bioethics Centre) provided ethical oversight of the project and Ministry of Health staff proffered advice.