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Triaging: Clinically suitable, socially debatable

26 May 2021

  • Could this solution to the scarcity of healthcare resources work in SL?

By Sumudu Chamara   With the third wave of Covid-19, which broke out following the Sinhala and Tamil New Year last month, Sri Lanka’s situation has started showing alarming signs of entering a grimly critical phase. Sri Lanka keeps recording larger numbers of Covid-19 cases and deaths caused by Covid-19 related complications with each passing day, and to make matters worse, the country is running out of resources to treat this increasing number of new cases. This month, Sri Lanka’s daily number of Covid-19 cases exceeded 3,000, while the total number of deaths passed the 1,000 mark. On the one hand, the capacity of hospitals and Intensive Care Units (ICUs), intermediate treatment facilities, and quarantine facilities keeps decreasing, and on the other hand, Sri Lanka is struggling to get enough vaccines to vaccinate all citizens.   Triaging Covid-19 patients in Sri Lanka Sri Lanka’s situation, as a matter of fact, has started showing signs of getting out of hand. A number of media reports as well as activists working in the health care system have revealed some disturbing statistics. Recently, one trade union had claimed that 46 Covid-19 patients were reported to have died at the Teldeniya Base Hospital within a period of just 15 days. The said media reports also alleged that there is a lack of ICU beds in the said hospital. Though the veracity of this claim has not been substantiated, the alleged reason, i.e. the lack of facilities to provide oxygen to the patients, resembles the situation prevailing in India. Even though this may be introduced as a solitary incident, it is important that we understand that what it reflects are inadequacies in the country’s healthcare system, or the failure to properly utilise the available resources. However, the health authorities can be seen taking various decisions to manage the impacts of the pandemic with the available resources. Taking into account the prevailing unfavourable situation, the health authorities recently decided to permit home quarantining for asymptomatic Covid-19 patients, and to use Ayurvedic treatment facilities as intermediate treatment centres, among many other decisions. It was reported recently that the health authorities are also considering adopting the method known as “triage”, as a potential relief to the issue of the lack of resources. This was reported by The Sunday Morning, quoting the State Minister of Primary Health Care, Epidemics, and Covid-19 Disease Control Dr. Sudarshini Fernandopulle. Neither the State Minister nor State Ministry officials were reachable for comment yesterday (24). However, the State Minister had told The Sunday Morning that triaging Covid-19 patients is being considered due to the possibility that Sri Lanka may not be able to manage the increasing Covid-19 cases in the near future, despite the large number of intermediate treatment facilities that have been set up and are being set up. In terms of admitting Covid-19 patients to hospitals under a system of triage, priority will be given to patients identified as vulnerable patients from older age groups who have pre existing medical conditions and complications, and before making an informed decision in this connection, medical staff will also take into consideration other factors, such as whether the patient is from a Covid-19 high risk area, the State Minister was reported as saying. She had also stated that medical staff are currently overwhelmed and that there is an excess of patients due to both symptomatic and asymptomatic Covid-19 patients being admitted to hospitals, and that if only patients with serious conditions are triaged and admitted to specialised units, medical staff will be able to handle the situation better. In the event the health authorities decide to triage Covid-19 patients, it would be started in the Kalutara District as a pilot project, and Director General of Health Services (DGHS) Dr. Asela Gunawardena had visited the relevant facilities in the District last week to look into the matters pertaining to this initiative, the aforementioned media report said.   Concept of triage The concept of triage refers to the process of prioritising people (who are in need of care) according to the severity or the urgency of their need for treatment. This method is especially used when there is a lack of resources to treat those who are seeking treatments, or when there is a large number of people seeking treatment at once. By triaging patients, responders maximise their time and resources and prevent non-urgent cases from being double or triple-checked unnecessarily. The method used in most countries at present consists of several levels, depending on the availability of resources and the nature of the treatment sought. Even though the health authorities are considering triage to deal with the Covid-19 pandemic, it had been in use for a long time, mostly in hospital emergency departments where critical patients come seeking treatment, especially after natural disasters or accidents.  However, the process of triaging has many classifications, and the strictest ones may even classify patients as those who are more likely to survive irrespective of the nature of the treatment they receive, those who are unlikely to live irrespective of the nature of the treatment they receive, and those who may have a positive change after immediate treatment.   Triaging Covid-19 patients around the world According to the World Health Organisation’s (WHO’s) Algorithm for Covid-19 Triage and Referral, the efficient triage of patients with Covid-19 at all health facility levels, namely primary, secondary, and tertiary, will help the national response planning and case management system to cope with the patient influx, assist to direct necessary medical resources to efficiently support the critically ill, and to protect the safety of healthcare workers. Primary facilities, secondary centres, tertiary hospitals, ICUs, and other designated facilities are identified as health facilities and referrals when triaging Covid-19 patients. Primary facilities include community health centres, primary health care facilities, specialty outpatient clinics, and private clinics, while secondary centres provide hospital services with specialist care and emergency departments.  These vary in the size, range, and level of services, the WHO said, adding that referral is based on whether the specific health service can meet a patient’s needs. Tertiary hospitals as treatment facilities have specialised staff, equipment, and services, including ICUs, and they may have advanced therapies, imaging, and laboratory services, the WHO said. The WHO identifies ICUs, which are currently a central topic of discussion in Sri Lanka due to their importance in treating patients showing critical complications, as another major treatment facility that is part of the triaging system. The WHO said that ICUs should normally have highly specialised staff, equipment, and facilities, as well as high clinician to patient ratios, and their capacity includes intensive monitoring, haemodynamic management, organ support, and life sustaining interventions. In addition, the WHO recognises other designated facilities (primary, secondary, and tertiary) chosen and prepared for Covid-19 screening, early recognition, diagnosis and severity assessment, referral, triage, and clinical care when discussing the triaging of Covid-19 patients. They should have trained staff, appropriate infection prevention and control measures in place, and a communication mechanism to discuss referrals with the patient receiving transport and health facilities, in order to be a part of a triage system, according to the WHO. According to the WHO Algorithm, triage and referral decisions depend on existing resources, local ethical considerations, and patient acceptance of referral. The WHO recommends that mild cases be referred to community care and be isolated, and says that depending on the country system in place, mild cases may be cared for at home, or in designated non-health facilities. If the conditions of patients deteriorate, they should be referred back to the primary and secondary facilities for reassessment. Also, this method includes both hospitalising patients in critical conditions in the first place, as well as referring Covid-19 patients to different levels of the healthcare system as their situation changes, after evaluating the symptoms and/or complications. The importance of identifying who needs to be treated first and more urgently is a matter of their situation and the nature of care they require. As health authorities in Sri Lanka have already noted, Sri Lanka’s healthcare facilities are currently struggling to treat both symptomatic and asymptomatic patients, when there is a good chance that most of them can be treated without hospitalising them. According to the WHO, current estimates show that 80% of confirmed Covid-19 cases could be treated as outpatients, while up to 20% of patients require hospitalisation for treatment. In addition, around 5% of patients need intensive care. When it comes to the global situation, many countries have triaged patients and treatment seekers during the Covid-19 pandemic, and some countries that were severely affected by the pandemic have adopted strict triaging methods due to the lack of resources, especially human resources and oxygen. Several researchers, while acknowledging the positive results and appropriateness of this method from a medical perspective, also say that socially, it is far from being fair or acceptable, as every person has the right to proper medical care. They also say that even though the process of prioritising those in urgent need of treatment is acceptable, every person’s medical needs should be considered fairly, and that the patients should also have a say in this process. The term triage, or the employment of it or practices amounting to it, were discussed widely after Hurricane Katrina destroyed New Orleans and several surrounding areas in the United States in 2005. Dr. Anna Pou of the Memorial Medical in New Orleans came under fire after it was alleged that she and several other members of the facility had euthanised several patients who were critically ill, as they did not have adequate resources to save them during the hurricane. Investigations had led to the belief that the deaths of up to 24 such patients could be homicides. However, after a months-long trial, a grand jury declined to indict any of the suspects in this connection. India’s Covid-19 situation is something Sri Lanka is always vigilant about, as the Indian variant of the Covid-19 virus has already entered Sri Lanka. Also, there is a fear among both the general and medical and scientific community that the limited amount of resources available in Sri Lanka, if left unaddressed, may worsen the country’s situation to something similar to India’s. India is one of the countries in the South Asian region that has adopted strict triage methods in some areas, according to Indian media. With regard to India’s situation, Indian media outlet Scroll said: “In the Indian context, who gets to claim health in an emergency is prefigured by who gets to claim health even in everyday situations. Triage by India’s debilitated tertiary care systems ignores the consequences of meting out emergency medicine in a public health system that is socially and culturally fragmented, and thus excludes the most marginalised from its ambit of care.” Foreign media also say that in other countries in the region such as Nepal, Bangladesh, Pakistan, and the Maldives, there are mechanisms which incorporate triaging, and that this method is prevalent at different levels in different forms in developed countries as well. Most countries have their own classifications as far as prioritising patients’ treatments is concerned.  Sri Lanka is still looking into the possibility of adopting this method, even though there are practices more or less amounting to triage when there is a shortage of resources. The number of Covid-19 cases and the availability of services are two factors that affect each other directly, and when cases increase, resources are exhausted, and when the resources are exhausted, managing the number of cases becomes difficult. To break this cycle, the health authorities have to make improvised and sometimes strict decisions. However, the priorities should not be subdued by short term measures, nor should they be considered long term measures. At the end of the day, the key to ending the pandemic still lies in one simple step – prevention.


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