Performance of crisis standards of care guidelines in a cohort of critically ill COVID-19 patients in the United States

Many US states published crisis standards of care (CSC) guidelines for allocating scarce critical care resources during the COVID-19 pandemic. However, the performance of these guidelines in maximizing their population benefit has not been well tested. In 2,272 adults with COVID-19 requiring mechanical ventilation drawn from the Study of the Treatment and Outcomes in Critically Ill Patients with COVID-19 (STOP-COVID) multicenter cohort, we test the following three approaches to CSC algorithms: Sequential Organ Failure Assessment (SOFA) scores grouped into ranges, SOFA score ranges plus comorbidities, and a hypothetical approach using raw SOFA scores not grouped into ranges. We find that area under receiver operating characteristic (AUROC) curves for all three algorithms demonstrate only modest discrimination for 28-day mortality. Adding comorbidity scoring modestly improves algorithm performance over SOFA scores alone. The algorithm incorporating comorbidities has modestly worse predictive performance for Black compared to white patients. CSC algorithms should be empirically examined to refine approaches to the allocation of scarce resources during pandemics and to avoid potential exacerbation of racial inequities. [Display omitted] Crisis standards of care (CSC) guidelines have poor prediction of 28-day mortalityConsideration of comorbidities modestly improves guideline performanceSimulation of clinical decision-making shows frequent ties in priority scoresUsing comorbidities in CSC has the potential to exacerbate racial inequities Jezmir et al. show that crisis standards of care (CSC) guidelines, used to allocate scarce medical resources, poorly discriminate 28-day mortality and result in frequently tied priority scores. The authors present a framework for testing CSC guidelines to ensure they meet their stated ethical goals.