Managing intensive care admissions when there are not enough beds during the COVID-19 pandemic: A systematic review

Carina S.B. Tyrrell*, Oliver T. Mytton, Sarah V. Gentry, Molly Thomas-Meyer, John Lee Y. Allen, Antony A. Narula, Brendan McGrath, Martin Lupton, Jo Broadbent, Aliko Ahmed, Angelique Mavrodaris, Anees Ahmed Abdul Pari

*Corresponding author for this work

    Research output: Contribution to journalReview articlepeer-review

    64 Citations (Scopus)
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    The surge in cases of severe COVID-19 has resulted in clinicians triaging intensive care unit (ICU) admissions in places where demand has exceeded capacity. In order to assist difficult triage decisions, clinicians require clear guidelines on how to prioritise patients. Existing guidelines show significant variability in their development, interpretation, implementation and an urgent need for a robust synthesis of published guidance. To understand how to manage which patients are admitted to ICU, and receive mechanical ventilatory support, during periods of high demand during the COVID-19 pandemic, a systematic review was performed. Databases of indexed literature (Medline, Embase, Web of Science, and Global Health) and grey literature ( and MedRxiv), published from 1 January until 2 April 2020, were searched. Search terms included synonyms of COVID-19, ICU, ventilation, and triage. Only formal written guidelines were included. There were no exclusion criteria based on geographical location or publication language. Quality appraisal of the guidelines was performed using the Appraisal of Guidelines for Research and Evaluation Instrument II (AGREE II) and the Appraisal of Guidelines for Research and Evaluation Instrument Recommendation EXcellence (AGREE REX) appraisal tools, and key themes related to triage were extracted using narrative synthesis. Of 1902 unique records identified, nine relevant guidelines were included. Six guidelines were national or transnational level guidance (UK, Switzerland, Belgium, Australia and New Zealand, Italy, and Sri Lanka), with one state level (Kansas, USA), one international (Extracorporeal Life Support Organization) and one specific to military hospitals (Department of Defense, USA). The guidelines covered several broad themes: use of ethical frameworks, criteria for ICU admission and discharge, adaptation of criteria as demand changes, equality across health conditions and healthcare systems, decision-making processes, communication of decisions, and guideline development processes. We have synthesised the current guidelines and identified the different approaches taken globally to manage the triage of intensive care resources during the COVID-19 pandemic. There is limited consensus on how to allocate the finite resource of ICU beds and ventilators, and a lack of high-quality evidence and guidelines on resource allocation during the pandemic. We have developed a set of factors to consider when developing guidelines for managing intensive care admissions, and outlined implications for clinical leads and local implementation.

    Original languageEnglish
    Pages (from-to)302-312
    Number of pages11
    Issue number3
    Early online date17 Dec 2020
    Publication statusPublished - 16 Feb 2021

    Bibliographical note

    Funding Information: We would like to thank Isla Kuhn, Head of Medical Library Services, University of Cambridge, for her assistance in our search strategy and conducting the literature searches. We would like to thank Public Health England for providing funding to make this work open access.
    The lead author is a National Institute for Health Research (NIHR) Academic Clinical Fellow (Postidentifier is ACF-2018-14-504).

    Open Access: This is an open access article distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited, appropriate credit is given, any changes made indicated, and the use is non-commercial. See:

    Publisher Copyright:© Author(s) (or their employer(s)) 2021. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.

    Citation: Tyrrell CSB, Mytton OT, Gentry SV, et al. Managing intensive care admissions when there are not enough beds during the COVID-19 pandemic: a systematic review. Thorax 2021;76:302-312.

    DOI: 10.1136/thoraxjnl-2020-215518


    • ARDS
    • assisted ventilation
    • critical care
    • respiratory infection
    • viral infection


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