Hamilton - In a pandemic more than twice as many patients will require intensive care, with less than half the usual staff available to provide it.

When the Hamilton Health Sciences (HHS) Pandemic Influenza Planning Committee contemplated how the triage process would be enacted at its hospitals, numerous gaps were identified:

* How is critical care triage operationalized in different care settings within the hospital (e.g., emergency department, hospital wards, ICU)?

* Who can function as a "triage officer"? What skills are required? If there is a single triage officer in each institution, what happens when these officers are needed in two places at once?

* Should these life and death decisions, made under extremely stressful circumstances, rest on the shoulders of single individuals? What are the risks of this model for triage officers and healthcare organizations? What supports do triage officers require?

* What procedural and institutional structures ensure triage decisions are of high quality, consistent (across time, triage officers and different hospitals), efficient, ethical and evidence-based? How should decisions be documented?

* What happens if the demand for critical care is so great that it cannot be managed using the Ontario Health Plan for an Influenza Pandemic process? How should choices be made between patients with the same clinical priority for critical care (i.e., SOFA score)?

Hamilton Health Sciences has developed a detailed critical care triage protocol for bedside application. In this article, we present (1) the rationale and process HHS undertook to create this protocol, (2) highlights and key innovations of the protocol and (3) issues arising from preliminary testing of the protocol.

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