A Practical Approach to Running a Scarce Resource Allocation Team (SRAT)

This guest post is authored by:

• Julia Lynch, PhD (University of Pennsylvania) @juliaflynch
• Isabel Perera, PhD (University of Pennsylvania)
• Theodore J Iwashyna, MD, PhD (VA Ann Arbor and University of Michigan) @iwashyna
• #Covisual illustration by Chelsea Harris, MD @CAHarrisMD

DISCLAIMER: “These do not necessarily represent the views of the U.S. Government or Department of Veteran Affairs.

Introduction

• There are numerous ethical frameworks^1-5 being proposed for how to fairly allocate scarce resources (e.g. ventilators) in the event that COVID-19 or another disaster overwhelms capacity 
• Asking bedside clinicians to make such triage decisions has many disadvantages:
  • Reduce trust between patients and their clinicians
  • Cause moral distress in clinicians feeling untenably conflicted
  • Will not be consistent across clinicians
  • Has a high risk of introducing bias and prejudice
• Therefore, many authorities recommend creating a “Scarce Resource Allocation Team” that will identify when “altered standard of care” is necessary, and design generalizable fair rules for triage
• However, there is almost no guidance on how such Scarce Resource Allocation Teams (SRATs) should conduct themselves
  • Badly run SRATs can be indecisive, dominated by handful of loud voices, or systematically ignore important perspectives
• We present an example of a charge that could be given to an SRAT to empower it, an bylaws to govern is function, based on collaboration between political scientists, bioethicists, and critical care medicine docs

Example SRAT Charge:

• The primary task of the Scarce Resource Allocation Team is to help frontline clinicians provide the best possible care for patients by identifying specific clinical situations where shortages require an alteration in practice from usual standard of care, and in those situation defining fair, transparent, and implementable allocation rules to define an alternative standard of care.  These rules will be first-and-foremost patient-centric and rooted in ethical principles laid out by the health system. 
• To support this task, the SRAT will actively and passively seek information about potential shortages from frontline clinicians, health system leadership, and other sources—helping to prevent/alleviate shortages wherever possible rather than define alternative standards of care. 
• The SRAT will inform the health system Incident Command Center about potential shortages and report on the SRAT’s recommendations regularly; will coordinate responses to care conflicts not rooted in shortages to the health system ethics team; and will work with the Incident Command Center  to constitute a distinct Triage Team to help implement allocation rules fairly in the event that they are challenging for bedside clinicians to implement themselves.
• The SRAT will follow pre-established processes of decision-making, document and report their decision, and recognize that time will often be of the essence.

SRAT Operations Guidelines

Tasks preparatory to the SRAT commencing work

Each hospital will need to undertake the following tasks in order to allow for SRAT functioning:

1. Define the SRAT membership and leadership structure.

• The SRAT shall consist of multi-specialty physician, nursing, physio-/respiratory therapy, environmental services, and other non-clinical staff members with relevant experience.
• To facilitate decision-making, we recommend the following leadership structure:
  • The TEAM LEADER shall be a senior MD drawn from the team membership.
  • The team shall be chaired by a Trichair consisting of the team leader, one team member who is an RN, and one non-clinician team member.
  • Appropriate alternates shall be designated as replacements for each member of the Trichair should the member be unable to perform their role.

2. Make explicit (and regularly update) the scope of decision making of the SRAT versus Incident Command, the Triage Team, and hospital ethics committee.

3. Outline (and regularly update) processes for referring issues to the SRAT.

4. Establish a regularly scheduled daily (including weekends) meeting time for the full SRAT.

5. Establish procedures and criteria for the Trichairs in consultation with referrers to triage issues according to the need for timeliness.

6. Establish procedures for recording SRAT decision-making processes and outcomes in an easily searchable, electronically accessible archive.

• Rigorous recording of SRAT decision-making processes and outcomes is critical for establishing transparency and accountability in scarce resource allocation. Ease of retrieval of previous decisions is important for establishing consistent application of the ethical principles outlined in the 2010 guidance.   
• Identify qualified staff to serve as point person for collecting decision forms, recording and compile notes of SRAT meetings, and archiving material. Legal staff may be particularly helpful in this role.
• Prepare a template for a note or other structured approach for recording processes and outcomes, and disseminate template to relevant staff.

7. Establish (and regularly update) procedures for disseminating guidance to relevant staff.

8. Work through example scenarios with SRAT in order to establish procedures and reinforce ethical principles.

SRAT procedures

The following procedures, summarized in the accompanying decision tree, should serve as the basis for SRAT decision-making.

1. Accepting issues

• When SRAT receives a request for guidance regarding scarce resource allocation, the SRAT Team Leader or their surrogate shall determine whether it falls within the scope of the SRAT.  
• If the issue is not within the scope of the SRAT, decision-making reverts to clinicians, the Triage Committee, incident command, the hospital ethics committee, or other appropriate decision-makers.
• If the issue is within the scope of the SRAT, the acceptance shall be recorded. 

2. Determining the time frame for SRAT action

• Once an issue has been accepted, the SRAT Team Leader or their surrogate shall determine whether it requires immediate resolution, can be deferred temporarily, or can safely be deferred until the next scheduled meeting of the SRAT. That decision shall be recorded.

3. Agenda-setting

• Issues accepted by the SRAT that can safely wait until the next scheduled meeting shall be assigned by the Team Leader in order of priority to a position on the “new business” part of the agenda.
• Issues decided between scheduled meetings of the SRAT shall be assigned to the “decisions rendered” section of the agenda for review.

4. Decision-making

If immediate resolution is required:

• If the issue cannot be resolved through means of regular clinical decision-making or using existing triage guidance, the Team Leader shall notify all team members via electronic message that an SRAT issue has arisen and solicit immediate input.  
• The Trichairs (or their alternates) shall then deliberate and render a decision. 
• 2/3 majority of the Trichairs (or their alternates) is required for a decision. 
• Notification of the decision shall be sent immediately to all SRAT members.
• The decision shall be recorded and realized.
• The issue shall be assigned to the “decisions rendered” section of the agenda of the next scheduled meeting of the SRAT, and reviewed by the full team. Review of decisions is essential to ensure consistency of application of ethical guidelines, since many decisions are likely to recur. Moreover, the necessity for an immediate decision constitutes a system failure and hence offers the SRAT an opportunity to discuss and improve system performance. 

If guidance can be deferred, but cannot safely wait until next scheduled meeting of SRAT:

• The Team Leader shall identify the SRAT members whose roles are most relevant to the issue in question.
• The Team Leader shall notify all team members via electronic message that an SRAT issue has arisen, soliciting immediate input and defining a timeline for response.
• A sub-group of the SRAT, composed of the Trichairs and the pre-identified most relevant SRAT members, shall then deliberate and vote on a proposed solution.
• If appropriate, ad hoc additional clinicians with specific relevant expertise, but not directly involved in the care of potentially effected patients, may be added for discussion of a given issue at the discretion to the Team Leader
• A 50% + 1 vote majority of the sub-group is required for a decision.
• Notification of the decision shall be sent immediately to all SRAT members.
• The decision shall be recorded and realized.
• The issue shall be assigned to the “decisions rendered” section of the agenda of the next scheduled meeting of the SRAT, and reviewed by the full team.

If the issue can safely wait until the next scheduled meeting:

• Prior to the scheduled meeting, the Team Leader shall set the order of agenda items and assign an SRAT member to be the issue lead. The issue lead shall identify possible solution(s) to all items on the “new business” section of the agenda. 
• At the scheduled SRAT meeting, the team shall address each item on the “new business” section of the agenda sequentially. For each issue, 
  • The issue lead shall present the problem and discuss its possible solution(s). 
  • The team will pose clarification questions for a pre-determined amount of time.
  • All present team members will vote on the proposed solution(s).
• If the result of the vote on any proposed solution is unanimous, the decision shall be recorded and realized. 
• If the result of the votes on proposed solutions are not unanimous, the team shall engage in a time-delimited deliberative process, consisting of the following steps:
  • If appropriate, ad hoc additional clinicians with specific relevant expertise, but not directly involved in the care of potentially effected patients, may be added for discussion of a given issue at the discretion of any of the Trichairs
  • Each SRAT member present at the meeting shall articulate a position and/or propose a solution (under pre-determined time limits).  It is essential that all members participate verbally at this stage as this will allow for a full range of voices to be represented in the decision-making.
  • All present members will participate in an open discussion of all the solutions proposed (under pre-determined time limits).
  • All present members shall vote on the proposed solutions using ranked-choice voting to determines the decision (see Box on ranked-choice voting including suggested resources for implementing the vote count.)
  • The decision shall be recorded and realized.

 5. Reviewing rendered decisions

• The “decisions rendered” section of each scheduled SRAT meeting shall be devoted to reviewing the decision-making processes and outcomes undertaken outside of regularly scheduled meetings.
• Decisions rendered outside of the regularly scheduled meetings, because they are rendered without full deliberation, may be considered an inferior basis for precedent. Therefore, reviewing past decisions not only provides an opportunity for reflection and learning, but also serves to establish a more sound basis for precedent in subsequent decision-making.

6. Recording and disseminating decisions

• The Team Leader or surrogate will report all issues taken up by the SRAT in a note (or other appropriate format established by the hospital). The note should include the following information: Who raised the issue to the Team Leader; which decision-making option the Team Leader pursued; who was involved in the decision-making process; which solutions were proposed and discussed; and the outcome of the voting procedure. The note should also include the rationale for each of these items.
• Once a decision has been rendered, a briefing describing the issue and the solution shall be sent to incident command and other relevant parties.

References

1. Emanuel EJ, Persad G, Upshur R, et al. Fair Allocation of Scarce Medical Resources in the Time of Covid-19 [published online ahead of print, 2020 Mar 23]. N Engl J Med. 2020;10.1056/NEJMsb2005114. doi:10.1056/NEJMsb2005114
2. National Center for Ethics in Health Care. Ethical Issues in Pandemic Influenza Preparedness and Response. [Accessed 29 March 2020] Available at URL: https://www.ethics.va.gov/activities/pandemic_influenza_preparedness.asp
3. Rosenbaum L. Facing Covid-19 in Italy – Ethics, Logistics, and Therapeutics on the Epidemic’s Front Line [published online ahead of print, 2020 Mar 18]. N Engl J Med. 2020;10.1056/NEJMp2005492. doi:10.1056/NEJMp2005492
4. Truog RD, Mitchell C, Daley GQ. The Toughest Triage – Allocating Ventilators in a Pandemic [published online ahead of print, 2020 Mar 23]. N Engl J Med. 2020;10.1056/NEJMp2005689. doi:10.1056/NEJMp2005689
5. White DB, Lo B. A Framework for Rationing Ventilators and Critical Care Beds During the COVID-19 Pandemic. JAMA. Published online March 27, 2020. doi:10.1001/jama.2020.5046

Further Reading

• Making RCTs Useful: The Role of Heterogeneity. Jack Iwashyna
• Should we put multiple COVID-19 patients on a single ventilator? Jack Iwashyna
• Mastering Intensive Care 020 with Jack Iwashyna