Volume 4, Issue 3 (Spring 2019)                   HDQ 2019, 4(3): 113-118 | Back to browse issues page

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Ghanbari V, Zareiyan A, Nejati A, Hanfiling D, Ardalan A. Ethical Patient Prioritization in Disaster Triage: A Protocol for a Systematic Review. HDQ. 2019; 4 (3) :113-118
URL: http://hdq.uswr.ac.ir/article-1-229-en.html
1- Department of Health in Disaster and Emergencies, School of Public Health, Tehran University of Medical Sciences, Tehran, Iran.
2- Department of Health in Emergencies and Disaster, Faculty of Nursing, Islamic Republic of Iran Army University of Medical Sciences, Tehran, Iran.
3- Center for Health Security, University of Pittsburgh Medical Center, Baltimore, The United States of America.
4- Department of Health in Disaster and Emergencies, School of Public Health, Tehran University of Medical Sciences, Tehran, Iran. , Aardalan@gmail.com
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1. Introduction
Adisaster is a serious event which disturbs the stricken community [1]. In respect of Medical Science, these events cause numerous casualties which their medical needs exceed the capacity of the responders for delivering timely and effective services [2, 3]. In this situation, the management of available resources has a pivotal role in disaster response outcomes [4, 5]. Triage can play an important role in addressing the issue of scarce medical resources in these situations [2, 6, 7]. 
Triage is the process of patient categorization and prioritization based on medical needs and allocation of resources to patients who have a chance to benefit from these resources [4, 7]. Recent evidence suggests that the process of triage is often unofficial or decisions are taken in an ad hoc fashion, and its practical aspects are implemented in different ways [8-10]. Hence, those who perform triage in disasters face a tough decision as to who should receive limited life-saving treatments or who may not benefit from such care [11, 12]. Nonetheless, life and death are the consequences of decisions in triage [12]. Therefore, decisions made in triage can put the decision-maker under a great deal of pressure [12]. 
Triage and allocation of limited resources in public health emergencies are still one of the most challenging issues in disaster medicine [13] because health care providers are not expected to make decisions to restrict the care of the patients or their rights [14]. Relying on ethical criteria for decision-making separates triage from arbitrary biased decisions based on personal judgment [12]. There is also an ethical obligation to have plans for decision-making in triage before an event occurs [11] and to guide clinical decisions during public health emergencies via ethical policies and processes [11, 14]. 
Although several studies have evaluated the criteria of ethical decision-making in disasters, there is no consensus on these criteria. Therefore, this study aims to obtain a comprehensive perspective of the proposed criteria for ethical decision-making in disasters triage.
2. Materials and Methods
This systematic review protocol has been submitted to the International Prospective Register of Systematic Reviews (http://www.crd.york.ac.uk/PROSPERO) (Registration Number: CRD42016040102). Preferred Reporting Items for Systematic review and Meta-Analysis Protocols (PRISMA-P)  will be used to develop this review protocol [15].
Type of studies
Researchers will include qualitative and review studies about resource allocation in public health emergencies. We also include case studies or editorials that describe ethical aspects of patient prioritization in disasters. We will exclude studies on resource allocation in health care settings in routine situations. We will also exclude articles that resource allocation, triage, or prioritization is not their main subject and explain these topics as part of disaster ethics. This review will not consider any specific participants or populations. In this review, we will investigate health care delivery to the people affected by a disaster. There is no restriction on the disaster types. Those studies will be assessed that investigated the ethical aspects of triage or prioritization of patients and resource allocation of medical resources in disaster situations. 
Information sources and search strategy
We will search the following electronic databases: PubMed, Web of Science, Scopus, and ProQuest, from 1990 until July 2017. Google Scholar, Global Health Library, Global Ethics library, World Health Organization, and Gray Literature Report will be searched using modified search syntax. We will also browse all issues of two journals with the highest records in the Scopus search from 1990 until July 2017 and will check article title to this review. The reference list of the eligible studies will also be assessed for possible relevant titles.
A search strategy will be developed based on a combination of the following factors: 1. MeSH terms and keywords related to disasters and ethics; 2. search strategy of a systematic review which assesses resource allocation in disasters and emergencies [9]. There is no language limitation in the search. The search strategy used for searching electronic databases is available in Appendix 1.
Data collection and extraction
All titles retrieved from electronic databases and other resources will be imported into an Endnote database. Duplicated references will be deleted, and then one of the reviewers (Vahid Ghanbari) will screen the titles. After that, the title and abstract assessment will be done by the first reviewer, and the second author will check the results. Predefined inclusion and exclusion criteria will be used to assess the full texts of the remaining titles. The excluded studies will be retained in a table with the reason for exclusion. Discrepancies will also be discussed to reach a consensus and, if necessary, the third author (Amir Nejati) will assess
opinions and take the final decision about the article. The process of selecting the studies will be documented in a PRISMA flow chart (Figure1).

Quality assessment
Quality assessment will be performed by an appropriate tool from the International Narrative Systematic Assessment tool (INSA) [16]. This step will be done by the first reviewer, and the second author will check the results. The selected articles will not be excluded in the quality assessment phase. A summary of the quality assessment scores will be provided. The quality of the evidence will be categorized as high, moderate, and low. Subgroup analysis will not be performed, and publication bias will not be assessed. 
3. Results
The primary outcome of this review will be factors that physicians or nurses must be considered when they want to decide on patient prioritization. The secondary outcome of this study will be ethical challenges reported in the decision-making process of prioritization of patients in disaster triage. The following data will be extracted from the selected articles: general information (the name of the first author, year, country, type of event), required factors to reach an ethical decision in prioritization of patients in disaster triage and ethical challenges that have been reported at triage, patient prioritization, or resource allocation in disaster. Only qualitative data will be extracted in mixed method studies. Data extraction will be done by Vahid Ghanbari, and the results will be imported into spreadsheets (Microsoft Excel).

4. Discussion
Scarcity is the main reason for resource allocation in the health care setting [17]. The shortage of resources worsens in disaster situations [18]. Triage decision-making in disaster events is intended to maximally provide the most benefit for the affected populations [19, 20]. One of the greatest challenges in disaster response is the process of patient prioritization in the context of making triage decisions [21, 22]. Therefore, clinical decision-making must be guided by ethical guidelines [21]. This systematic review is expected to provide appropriate evidence for patient prioritization according to ethical principles. Another objective of this study is to address the ethical challenges that care providers face during triage in disasters.
5. Conclusion
There are different perspectives regarding how the greatest goods for the greatest number can be achieved in disaster triage. To reach transparency and consistency in a disaster situation, the decision-making criteria should be clear. By identifying and applying these criteria in decision making, not only these ethical values will be respected, but also the moral distress which triage officer may experience during or after a decision will be decreased.  
Ethical Considerations
Compliance with ethical guidelines

All ethical principles were considered in this article. The participants were informed about the purpose of the research and its implementation stages; they were also assured about the confidentiality of their information; Moreover, They were allowed to leave the study whenever they wish, and if desired, the results of the research would be available to them.
The present paper was extracted from the PhD thesis of the first author, Vahid Ghanbari, Department of Health in Disaster and Emergencies, School of Public Health, Tehran University of Medical Sciences.
Authors' contributions
Conceived the study idea, extract the data: Vahid Ghanbari; developing the study protocol: Ali Ardalan, Amir Nejati, Vahid Ghanbari, Dan Hanfiling; Designing the search strategy and search syntax: Vahid Ghanbari; Performing the search and import the results into endnote: Vahid Ghanbari; Title and abstract screening, full-text selection, check the quality of the selected article: Vahid Ghanbari and Armin Zareiyan; Read and approve the article: All authors.
Conflict of interest
The authors declared no conflict of interest.
The authors would like to acknowledge the Consultation Unit, Office of Publications and Scientometrics, Tehran University of Medical Sciences for editing of the manuscript in English. Also, the authors appreciate Dr. Alireza Bagheri and Dr. Abasali Keshtkar for their valuable comments. 

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Type of Study: Review | Subject: Special
Received: 2018/09/12 | Accepted: 2018/11/24 | Published: 2019/07/23

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