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In Victoria, whether you get an ICU bed could depend on the hospital

Introduction by Croakey: Prime Minister Scott Morrison announced yesterday that the Federal Government had signed an agreement with UK-based pharmaceutical company AstraZeneca to manufacture and supply a COVID-19 vaccine.

“Under the deal, every single Australian will be able to receive the University of Oxford COVID-19 vaccine for free, should trials prove successful, safe and effective,” Morrison said in a statement.

However, Shadow Health Minister Chris Bowen noted today (19 August) that AstraZeneca had said the letter of intent the company signed did not “go to any detail about the costs or numbers or anything until we have an idea of what the manufacturing capacity is – that’s a critical piece of the puzzle”. 

According to Bowen, the company further stated: “There is a letter of intent which is a good first step, a critical next step is to determine manufacturing capacity.”

Bowen renewed calls for the Federal Government to “sign advance supply agreements not only with AstraZeneca, but with other vaccines under development as well to ensure that Australians have the best chance to get access to the vaccine as soon as it’s ready to roll”. 

While Morrison had suggested in a radio interview this morning that a coronavirus vaccine would be mandatory as soon as it was made available, he later stepped back from this statement.

“It’s not going to be compulsory to have the vaccine,” the ABC reported him telling a Sydney radio station.

Vaccine or no vaccine, one thing is clear: COVID-19 will be impacting our health system for the forseeable future. And the equitable distribution of health resources — both internationally and in Australia — will remain a challenge.

Earlier this week, the World Health Organization’s Director-General Dr Tedros Adhanom Ghebreyesus said in a media briefing that WHO was “working with governments and the private sector to both accelerate the science, through the ACT-Accelerator, and ensure that new innovations are available to everyone, everywhere starting with those at highest risk”.

“Since May, WHO has been in extensive consultations to develop a new framework to guide fair and equitable access to diagnostics, therapeutics and vaccines, for COVID-19 across all countries.

“These cross-cutting principles are key to the promotion of equitable access and fair allocation of these essential health products for the greatest impact globally,” he said. “For example, once a successful vaccine has been identified WHO’s strategic advisory group will provide recommendations for their appropriate and fair use.”

The Federal Government yesterday launched Australia’s COVID-19 Vaccine and Treatment Strategy outlining how the Government is “investing in promising vaccines and treatments and how they will be safely, fairly and rapidly delivered to Australians”.

In the article below, Drs Lisa Mitchell and Emma Tumilty of Deakin University and Associate Professor Giuliana Fuscaldo of Monash University, write that Victorian hospitals have variable approaches to rationing medical resources, including intensive care beds. They call on Safer Care Victoria and individual health services to make their ethical framework document and resource allocation procedures publicly available.

This article first appeared in The Conversation.


Lisa Mitchell, Emma Tumilty, and Giuliana Fuscaldo write:

Although most hospitals are coping right now, COVID-19 has brought up many questions about how health care resources should be rationed during a pandemic.

Ideally, every unwell person should get anything they need to get better. But important resources like medications and hospital beds, including intensive care unit (ICU) beds, can become limited if demand outstrips supply.

We’ve had access to confidential documents outlining how various health services are to make decisions on who gets ICU resources in the event they become overwhelmed.

We found there’s significant variation between hospitals’ procedures on this front. And worryingly, the public doesn’t have access to this information.

Resource allocation in hospitals

Resource allocation procedures or triage plans help to work out who gets that bed, ventilator, or vaccine if and when the system comes under significant strain.

Ideally, these procedures should be created well ahead of when they might be needed, and be underpinned by three factors:

  • Local context — what’s available/possible
  • Medical evidence — what works, and for whom
  • Ethical values — what we consider fair and the right thing to do.

The Victorian Pandemic Plan suggests health services should “adopt a systematic and transparent prioritisation of services as demand for treatment grows”.

It also says: 

Triage will be enacted at the same level across the state, to promote equity of access of patients to intensive care.”

Safer Care Victoria, the peak state body for quality and safety improvement in health care, had been preparing a document to guide hospitals on ethical resource allocation. But it only released this to the health services a few days ago, and the contents are considered sensitive and not for wider distribution within or outside the health services.

In contrast, Queensland Health released an ethical framework to guide clinical decision-making during COVID-19 in April, that’s available to the public.

Different hospitals, different procedures

In the absence of a statewide approach in Victoria, most health services have developed their own resource allocation documents and triage plans.

To our knowledge, none of these documents are publicly available. But we’ve been able to informally review COVID-19 resource allocation procedures from a number of Victorian hospitals.

We’ve found these procedures vary in how ICU resources would be allocated to sick people (with or without COVID-19) in the event resources were scarce.

Some health services would use a standardised scoring system that predicts short-term survival (that is, the person deemed most likely to live would get the bed). But when they use the scoring system, and what additional criteria they take into account, varies between hospitals.

Some hospitals would use exclusion criteria based on certain health conditions. The types of conditions vary between hospitals. For example, one hospital would use a body mass index (BMI) above 40 to exclude people who are obese, while another would exclude people with alcohol dependency.

In “tie-breaker” situations, when it’s not possible to make a decision based on the scoring system, health conditions, or the severity of illness alone, hospitals may use tie-breaker criteria.

Tie-breaker criteria were also different across different hospitals. Some hospitals would prioritise pregnant people, sole parents, health-care workers, and so on. Others would not.

Several of the hospitals plan to use a team of experienced clinicians not involved in the patient’s care as a triage team. Some hospitals have indicated a lottery is the fairest thing to do in tie-breaker situations.

Hospital x, y or z?

Most hospital patients won’t need ICU-level support. Some people, even if they’re very unwell, may choose not to receive treatment in the ICU. And some people will not benefit from ICU care. But for anyone who might benefit, the different plans could mean different access depending on which hospital they go to.

For example, if you’re pregnant, it would be better to go to hospital x. If you’re a widowed parent with young children, you should go to hospital y. If you’re obese, you should try your luck somewhere other than hospital z.

Again, these resource allocation procedures are not publicly available, so we can’t provide information here to guide you.

Variation in procedures across different hospitals is understandable in the face of uncertain medical evidence, or when available resources differ in local contexts, or because local communities have specific health needs. For example, you could reasonably expect variation between a smaller regional hospital and a bigger city hospital.

But where resources are similar — for example in two Melbourne hospitals only a few kilometres from each other, with overlapping catchment areas — plans should essentially be the same. If they’re not the same they should at least be publicly available.

It appears they vary, and the current lack of transparency around these resource allocation procedures means patients have no way of knowing whether they would be better to present at one emergency department over another.

Transparency and equity

The pandemic has highlighted various health inequities. In Victoria, the highest case numbers have occurred in areas with the greatest socioeconomic disadvantage.

Resource allocation is considered fair when processes are accountable, transparent, justifiable, and revisable. Where they’re not, they can further disadvantage people and communities.

If Safer Care Victoria and the individual health services were to make their ethical framework document and resource allocation procedures available to the public, this would allow for discussion and engagement, and where possible, enable people to choose which health service will serve them best.

Dr Lisa Mitchell is Conjoint Clinical Senior Lecturer in the School of Medicine, Faculty of Health, Deakin University, Dr Emma Tumilty is Lecturer at Deakin University, and Associate Professor Giuliana Fuscaldo is from Monash University.

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Croakey Conference News Service 2013 – 2019
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Closing the Credibility Gap 2013
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Health Workforce Australia 2013
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AIDA Conference 2014
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National Suicide Prevention Conference 2014
Racism and children/youth health symposium 2014
Rural & Remote Health Scientific Symposium 2014
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