In a COVID crisis, triage standards may worsen racial disparities in treatment

During the crush of the COVID-19 pandemic, overwhelmed doctors and nurses in some places have had to make agonizing decisions about which patients should receive scarce health care resources. However, two Yale-led research studies suggest that a standard measurement designed to help predict which patients have the best chances of survival — and who therefore should receive treatment — could promote racial disparities of treatment outcomes.

In one of the studies, published Sept. 16, researchers found that Black patients admitted to Yale New Haven Health System hospitals with COVID-19 typically have higher Sequential Organ Failure Assessment (SOFA) scores — a measurement developed two decades ago to predict outcomes of hospital patients suffering from sepsis — than white patients. (The higher a patient's SOFA score, according to the standard, the lower their chances for survival.)

The other study showed that while Black patients admitted in the Yale New Haven Health System tended to have higher SOFA scores than those from other racial or ethnic groups, their mortality rate was about the same.

Both papers were published in the journal PLOS One.

“If we adopt this protocol, we could end up disproportionally steering resources away from Black patients and towards other groups,” said Benjamin Tolchin, director of Yale New Haven Health’s Center for Clinical Ethics, and corresponding author of the second paper, published on Sept. 17.

Since the earliest days of the pandemic, some health facilities have been forced to triage patients based on limited supplies. During the first wave of infections in the spring of 2020, some hospitals in northern Italy and New York City lacked the staff and equipment — such as ventilators and hemodialysis machines — needed to assist all emergency cases.

“What happened was that clinicians were making resource allocations decisions on a case-by -case basis, with some preference given to younger patients who were less likely to die from severe infection,” Tolchin said.

While some hospitals began contemplating the use of crisis standard of protocols — including those that rely on criteria such as SOFA scores — during future crises, these protocols have rarely been used. In Idaho, however, physicians have been forced to ration medical care in response to the latest surge in infections and have adopted SOFA scores as criteria for making these decisions.

Developed in 1996, the Sequential Organ Failure Assessment scoring system calculates the mortality of patients with sepsis based on the function of six organ systems.

“When we looked at this earlier this year, we were thinking of devising crisis standard of care recommendations that might be adopted in future pandemics,” Tolchin said. “We didn’t think we would be needing them so quickly.”

Other lead authors of the papers include Carol Oladele, assistant professor in the section of General Internal Medicine at Yale and a core faculty member at the university’s Equity Research and Innovation Center (ERIC), and Shireen Roy, a recent graduate of Yale College and Yale School of Public Health who is now a medical student at Washington University School of Medicine. Roy is the corresponding author of the paper published Sept. 16.