Is triage coming?

By Bill Peckham

RenalWEB links to four articles - three from JAMA (with introduction) and one overview from Reuters - reporting cases of severe complications from H1N1 illness. These severe cases are already straining ICU infrastructure causing the JAMA editors to worry as they look ahead:

Hospitals must develop explicit policies to equitably determine who will and will not receive life support should absolute scarcity occur. The controversy that erupted around triage decisions during Hurricane Katrina highlights the importance of advance planning and clear guidelines.10 Several groups have provided recommendations for allocating scarce therapies during the influenza pandemic.11-13 Any deaths from 2009 influenza A(H1N1) will be regrettable, but those that result from insufficient planning and inadequate preparation will be especially tragic.

This is another way of saying hospitals will need to impose triage guidelines.

I first wrote about dialyzors being on the wrong side of the pandemic triage framework in March of '08 (I was thinking of a different virus at the time: H5N1), Peter wrote about the potential triage threat with regard to H1N1 in August. Now as the pandemic is slowly unfolding instances of triage being used will increase. The most recent CDC FluView (for week 39) shows the trend - hospitalizations and deaths are increasing in advance of the normal flu season.

Dialysis units have not reported any problems related to the flu - the Kidney Community Emergency Response Coalition monthly calls have continued to emphasize preparedness (September minutes PDF link). Thus far the virus has been spreading in schools, there have been no reported breakouts in hospitals, clinics, businesses or hotels. There has not been a lot of adult to adult spread, which is great but with flu we can't say why. It could be that adults have some protection gained from previous bouts with flu or it could be something about the way the flu spreads. At this point we can say it is spreading more easily among young people but we don't know why and we don't know if that will continue.

Comments

[Peter Laird, MD]

The two best defenses against any influenza virus is first social distancing and secondly acquired herd immunity. The importance of early vaccination in the dialysis and renal population is paramount to preventing the onset of severe illness that would generate the need for triage at our local emergency rooms. In the mean time, avoidance of large crowds will be the first line of defense. With the onset of rapidly increasing infections it is now time to implement these protective behaviors to avoid the need for treatment.