Physician experiences of critical care triage during the COVID-19 pandemic: a scoping review
Authors: Smith Eric , Kulasegaran Nandini , Cairns Will , Evans Rebecca , Woodward Lynn 
Published: May 2024

Abstract
Background
Coronavirus Disease 2019 (COVID-19) overwhelmed health systems globally forcing doctors to make difficult triage decisions where healthcare resources became limited. While there have been several papers surveying the views of the public surrounding triage decisions in various disasters and many academic discussions around the moral distress suffered by physicians because of this, there is little research focussed on collating the experiences of the affected physicians in the critical care setting themselves.

Objective
The objective of this scoping review is to consolidate the available scientific literature on triage experiences and opinions of doctors (hereby used synonymously with physicians) working in the critical care setting during the COVID-19 pandemic, particularly on issues of moral distress and the role of triage guidelines. In addition, this paper attempts to identify common themes and potential gaps related to this topic.

Methods
A comprehensive scoping review was undertaken informed by the process outlined by Arksey and O’Malley. Seven electronic databases were searched using keywords and database-specific MeSH terms: CINAHL, Emcare, Medline, PsychINFO, PubMed, Scopus and Web of Science. Google Scholar and references of included articles were subsequently scanned. Included studies had to have an element of data collection surveying physician experiences or opinions on triage with a critical care focus during the COVID-19 pandemic from January 2020 to June 2023. A thematic analysis was subsequently performed to consider physicians’ perspectives on triage and collate any recurrent triage concerns raised during the pandemic.

Results
Of the 1385 articles screened, 18 were selected for inclusion. Physicians’ perspectives were collected via two methods: interviews (40%) and surveys (60%). Sixteen papers included responses from individual countries, and collectively included: United States of America (USA), Canada, Brazil, Spain, Japan, Australia, United Kingdom (UK), Italy, Switzerland and Germany, with the remaining two papers including responses from multiple countries. Six major themes emerged from our analysis: Intensive Care Unit (ICU) preparedness for triage, role and nature of triage guidelines, psychological burden of triage, responsibility for ICU triage decision-making, conflicts in determining ICU triage criteria and difficulties with end-of-life care.

Conclusions
While most studies reported critical care physicians feeling confident in their clinical role, almost all expressed anxiety about the impact of their decision-making in the context of an unknown pandemic. There was general support for more transparent guidelines, however physicians differed on their views regarding level of involvement of external ethics bodies on decision-making. More research is needed to adequately investigate whether there is any link between the moral distress felt and triage guidelines. In addition, the use of an age criterion in triaging criteria and the aetiology of moral distress requires clearer consensus from physicians through further research which may help inform the legislative reform process in effectively preparing for future pandemics.