Skip to main content

The triage dilemma: opening Pandora's box... ever so slowly

I applaud the efforts by Michael Christian and colleagues [1] in taking on the difficult dilemmas surrounding triage management and training tied to surge capacity and resource allocation within intensive care settings during pandemics. Studies on triage protocols arose primarily from critical care professionals awakened to those responsibilities during severe acute respiratory syndrome and then re-challenged during the current H1N1 pandemic [24].

In reality, intensive care units with their professional staff and high-tech equipment represent a major limiting factor for most communities. The most plausible scenario for a viral pathogen of greater severity and lethality is that emergency departments and hospital wards will be deluged with critical care patients, the challenge being how to provide 'opportunities for survival' by transferring some semblance of critical care services and expertise to these 'non-critical care' settings. Discipline-directed triage management protocols will only be as important as the manner in which these tertiary level algorithms can be integrated into a larger system-wide triage scheme that begins at the primary triage care level and ends with whatever additional resources a regional support system can mobilize. Many 'uncomfortable but real' decisions that have not, to date, been operationalized at the local level will be made.

Triage management requires an infrastructure, such as health emergency operations centers (HEOCs), where central triage committees, operationalized ethical resources, palliative care guidance, data collection and analysis, and communication capacities provide high-level situational awareness for simultaneously initiating triage and modifying protocols at all health facilities and their individual triage teams [5]. While attempts to provide independent hospital-centric plans are noble, they do not solve what ultimately requires an integrated population-based system-wide solution [6].

Triage is an imperfect but necessary 'art and science' whether based on good clinical judgment or informed by protocols that attempt to direct resources to those most likely to benefit. Critical care studies opened Pandora's box. What follows requires much more input from other disciplines and society itself. Although it may first seem like one is trespassing professional boundaries, the investment in integrated preparedness and effective surge strategies, including system-wide triage, is crucial to minimize the need for rationing at all levels of care.


  1. 1.

    Christian MD, Hamielec C, Lazar NM, Wax RS, Griffith L, Herridge MS, Lee D, Cook DJ: A retrospective cohort pilot study to evaluate a triage tool for use in a pandemic. Crit Care 2009, 13: R170. 10.1186/cc8146

    PubMed Central  Article  PubMed  Google Scholar 

  2. 2.

    Christian MD, Hawryluck L, Wax RS, Cook T, Lazar NM, Herridge MS, Muller MP, Gowans DR, Fortier W, Burkle FM: Development of a triage protocol for critical care during an influenza pandemic. CMAJ 2006, 175: 1377-1381.

    PubMed Central  Article  PubMed  Google Scholar 

  3. 3.

    Kumar A, Zarychanski R, Pinto R, Cook DJ, Marshall J, Lacroix J, Stelfox T, Bagshaw S, Choong K, Lamontagne F, Turgeon AF, Lapinsky S, Ahern SP, Smith O, Siddiqui F, Jouvet P, Khwaja K, McIntyre L, Menon K, Hutchison J, Hornstein D, Joffe A, Lauzier F, Singh J, Karachi T, Wiebe K, Olafson K, Ramsey C, Sharma S, Dodek P, Canadian Critical Care Trials Group H1N1 Collaborative: Critically ill patients with 2009 influenza A (H1N1) infection in Canada. JAMA 2009, 302: 1872-1879. 10.1001/jama.2009.1496

    Article  CAS  PubMed  Google Scholar 

  4. 4.

    Devereaux AV, Dichter JR, Christian MD, Dubler NN, Sandrock CE, Hick JL, Powell T, Geiling JA, Amundson DE, Baudendistel TE, Braner DA, Klein MA, Berkowitz KA, Curtis JR, Rubinson L, Task Force for Mass Critical Care: Definitive care for the critically ill during a disaster: a framework for allocation of scarce resources in mass critical care. Task Force for Mass Critical Care. Chest 2008,133(5 Suppl):51S-66S. 10.1378/chest.07-2693

    Article  PubMed  Google Scholar 

  5. 5.

    Burkle FM Jr, Hsu EB, Loehr M, Christian MD, Markenson D, Rubinson L, Archer FL: Definition and functions of health unified command and emergency operations centers for large-scale bioevent disasters within the existing ICS. Disaster Med Public Health Prep 2007, 1: 135-141. 10.1097/DMP.0b013e3181583d66

    Article  PubMed  Google Scholar 

  6. 6.

    Frolic A, Kata A, Kraus P: Development of a critical care triage protocol for pandemic influenza: integrating ethics, evidence and effectiveness. Healthc Q 2009, 12: 54-62.

    Article  PubMed  Google Scholar 

Download references

Author information



Corresponding author

Correspondence to Frederick M Burkle Jr.

Additional information

Competing interests

The author declares that they have no competing interests.

Rights and permissions

Reprints and Permissions

About this article

Cite this article

Burkle, F.M. The triage dilemma: opening Pandora's box... ever so slowly. Crit Care 14, 401 (2010).

Download citation


  • Critical Care
  • Situational Awareness
  • Severe Acute Respiratory Syndrome
  • H1N1 Pandemic
  • Triage Management