What if 5 patients come to the emergency department at the same time. And what if all 5 patients need admission to the ICU and need to be put on a ventilator but there are only 2 ICU beds and only 2 ventilators available? How can this decision be made so that it is ethical, humane, fair and justifiable?
The medical doctors attempting to make this decision will likely reach out to a bioethicist for advice.
In a real case involving these 5 patients, the bioethicist advised the medical doctors to use the SOFA scoring system in order to choose. This score will predict those critically ill patients who are more likely to live.
The Sequential Organ Failure Assessment (SOFA) score is a simple and objective score that allows for calculation of both the number and the severity of organ dysfunction in six organ systems (respiratory, coagulatory, liver, cardiovascular, renal, and neurologic) , and the score can measure individual or aggregate organ dysfunction .
Table 1
The Sequential Organ Failure Assessment (SOFA) score
| SOFA score | 1 | 2 | 3 | 4 |
|---|---|---|---|---|
| Respirationa | ||||
| PaO2/FIO2 (mm Hg) | <400 | <300 | <220 | <100 |
| SaO2/FIO2 | 221-301 | 142-220 | 67-141 | <67 |
| Coagulation | ||||
| Platelets ×103/mm3 | <150 | <100 | <50 | <20 |
| Liver | ||||
| Bilirubin (mg/dL) | 1.2-1.9 | 2.0-5.9 | 6.0-11.9 | >12.0 |
| Cardiovascularb | ||||
| Hypotension | MAP <70 | Dopamine ≤5 or dobutamine (any) | Dopamine >5 or norepinephrine ≤0.1 | Dopamine >15 or norepinephrine >0.1 |
| CNS | ||||
| Glasgow Coma Score | 13-14 | 10-12 | 6-9 | <6 |
| Renal | ||||
| Creatinine (mg/dL) or urine output (mL/d) | 1.2-1.9 | 2.0-3.4 | 3.5-4.9 or <500 | >5.0 or <200 |
MAP, mean arterial pressure; CNS, central nervous system; SaO2, peripheral arterial oxygen saturation.aPaO2/FIO2 ratio was used preferentially. If not available, the SaO2/FIO2 ratio was usedbvasoactive mediations administered for at least 1 hr (dopamine and norepinephrine μmg/kg/min).
And now we know what tool that medical doctors should use ( SOFA) in the ER when attempting to triage very sick patients who arrive at the same time.
The results of studies suggest that the SOFA score functions with fair to good accuracy for predicting in-hospital mortality at the time of ED presentation. Furthermore, we found that the Δ SOFA over 72 hours has a statistically significant positive relationship to in-hospital mortality. These data suggest that use of the SOFA score is an acceptable method for risk stratification and prognosis of patients at the time of ED presentation. Using absolute values or changes over time, the SOFA score appears to be a potentially useful tool for either the clinician during bedside assessment.
Raymond Rupert patient advocate & healthcare consultant.