Triage standards during pandemic may worsen racial disparities in treatment

A tool used to measure chances of survival — and who therefore should receive treatment — could be promoting disparate outcomes for Black COVID-19 patients.
Healthcare workers in hazmat suits looking at a clipboard.


During the worst of the COVID-19 pandemic, overwhelmed doctors and nurses in some places have had to make agonizing decisions about which patients should receive scarce health care resources. Some hospitals have contemplated using a standard measurement to guide these decisions. But two new Yale-led studies suggest that the protocol known as SOFA could promote racial disparities in treatment outcomes.

Developed two decades ago to assess illness severity among patients with sepsis, SOFA — Sequential Organ Failure Assessment — was designed to help predict which patients have the best chances of survival. A patient with a high SOFA score, according to the protocol, has a lower chance for survival.

In one of the new studies, published Sept. 16, researchers found that Black patients with COVID-19 admitted to Yale New Haven Health System hospitals typically have higher SOFA scores than white patients do.

The other study showed that while Black patients admitted in the Yale New Haven Health System tended to have higher SOFA scores than those from other racial or ethnic groups, their mortality rate was about the same.

If we adopt this protocol [SOFA], we could end up disproportionally steering resources away from Black patients and towards other groups,” said Benjamin Tolchin, director of Yale New Haven Health’s Center for Clinical Ethics, and corresponding author of the second paper, published on Sept. 17.

The Yale New Haven Health System is not using SOFA to guide patient care or inform allocation of resources. But other U.S. hospitals have used the scores as a tool for rationing care during the recent surge in COVID-19 cases.

Both papers were published in the journal PLOS One.

Since the earliest days of the pandemic, some health facilities have been forced to triage patients based on limited supplies. During the first wave of infections in the spring of 2020, some hospitals in northern Italy and New York City lacked the staff and equipment — such as ventilators and hemodialysis machines — needed to assist all emergency cases.

What happened was that clinicians were making resource allocations decisions on a case-by-case basis, with some preference given to younger patients who were less likely to die from severe infection,” Tolchin said.

While some hospitals began contemplating the use of crisis standard protocols — including those that rely on criteria such as SOFA scores — these protocols had not been used until recently. In Idaho late this summer, for example, physicians were forced to ration medical care in response to the latest local surge in infections, adopting SOFA scores to guide these decisions.

Developed in 1996, the SOFA system calculates the mortality of patients based on the function of six organ systems.

When we looked at this earlier this year, we were thinking of devising crisis standard of care recommendations that might be adopted in future pandemics,” Tolchin said. “We didn’t think we would be needing them so quickly.”

Other lead authors of the papers include Carol Oladele, assistant professor in the section of General Internal Medicine at Yale and a core faculty member at the university’s Equity Research and Innovation Center (ERIC), and Shireen Roy, a recent graduate of Yale College and Yale School of Public Health who is now a medical student at Washington University School of Medicine. Roy is the corresponding author of the paper published Sept. 16.

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Part of the In Focus Collection: Yale responds to COVID-19

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