Multi-Factor Triage Algorithm (MUFTA): Quantitative and Qualitative Ethical Factors on Triage Decisions During COVID-19

Shamsuddin Ahmed, Rayan H. Alsisi


Background: This study shows how multiple ethical criteria evaluations result in patient screening and ranking. Furthermore, as Omicron outbreaks increase, hospital emergency departments will become overburdened with critically ill patients. It is a one-of-a-kind global triage algorithm for infectious decreases of COVID-19 and Omicron. The algorithm is qualitative and quantitative, and adaptable to various bio-ethical and social factors. The measurement of the evaluation process eliminates any inconsistencies, which is an advantage of a decision-making algorithm. The proposed algorithm is unique because there are no similar algorithms in the literature that provide triage guidelines based on social ethics, bioethics, and human dignity. Objective: It's simple to evaluate a patient's potential benefits when ethical triage judgments are structured and transparent. Furthermore, decisions made primarily based on economic considerations in stressful situations overlook the socioeconomic realities of the underprivileged. This triage algorithm eliminates the need for ad hoc triage evaluations and facilitates criteria for inclusion, such as human dignity. It also takes into account patient comorbidities and social, ethical issues. Method: Healthcare professionals use predefined ethical criteria to assign relative rankings among patients based on treatment response and social circumstances. It is a Delphi method for evaluating patient illnesses with the help of medical professionals. For example, the admission to the intensive care unit and providing a ventilator depend entirely on hierarchical multidimensional triage scoring results. This algorithm can evaluate triage scores quickly. It is robust, accurate, and quick in assessment, evaluation, and reevaluation during an emergency. A team of three experts can implement this algorithm. Result: The Consistency Scores (CR) show how well clinical and non-clinical ethical criteria may be used to make triage judgments. As a result, all specialists have reported allogeneic reactions in the triage assessment. Furthermore, this system enables decision-makers to identify cognitive biases that may influence their decisions. A Group Consciousness Ratio (GCR) of over 85% indicates that the decision-making process is transparent. Patients with a high level of social dependency, a reasonable probability of recovery, a favorable weighted average comorbidity score, and those who are less fortunate are all considered in the overall triage decision. Conclusions: This algorithm differentiates patients who need ICU (Incentive Care Unit) care and do not immediately require critical resources. As a result, patients queue up on a waiting list when the ICU demand spikes due to the increased incidence of COVID-19 infection or its variants. This situation presents a dilemma for the triage policy. Therefore, a national emergency policy requires monetary and technical assistance to expand healthcare facilities. However, the clarity of this triage policymaking is at odds with decision-makers interested in manipulating results. It is challenging to deal with consistency issues in the Delphi process in group decision-making without professional moderators and valid evaluation metrics. Therefore, transparency, consistency, and strong judgment are essential elements of the presented algorithm.


Doi: 10.28991/esj-2022-SPER-07

Full Text: PDF


Triage; Multi-Factor Triage Algorithm (MUFTA); Social Ethics; Decision Making; Covid-19; Patient Prioritization.


Emanuel, E. J., Persad, G., Upshur, R., Thome, B., Parker, M., Glickman, A., ... & Phillips, J. P. (2020). Fair allocation of scarce medical resources in the time of Covid-19. New England Journal of Medicine, 382(21), 2049-2055. doi: 0.1056/NEJMsb2005114.

De Panfilis, L., Di Leo, S., Peruselli, C., Ghirotto, L., & Tanzi, S. (2019). “i go into crisis when ...”: Ethics of care and moral dilemmas in palliative care. BMC Palliative Care, 18(1). doi:10.1186/s12904-019-0453-2.

Tanzi, S., Alquati, S., Martucci, G., & De Panfilis, L. (2020). Learning a palliative care approach during the COVID-19 pandemic: A case study in an Infectious Diseases Unit. Palliative Medicine, 34(9), 1220–1227. doi:10.1177/0269216320947289.

Curtis, J. R., & Vincent, J. L. (2010). Ethics and end-of-life care for adults in the intensive care unit. The Lancet, 376(9749), 1347–1353. doi:10.1016/S0140-6736(10)60143-2.

Gómez-Vírseda, C., De Maeseneer, Y., & Gastmans, C. (2019). Relational autonomy: What does it mean and how is it used in end-of-life care? A systematic review of argument-based ethics literature. BMC Medical Ethics, 20(1). doi:10.1186/s12910-019-0417-3.

White, D. B., & Lo, B. (2020). A Framework for Rationing Ventilators and Critical Care Beds during the COVID-19 Pandemic. JAMA - Journal of the American Medical Association, 323(18), 1773–1774. doi:10.1001/jama.2020.5046.

Matheny Antommaria, A. H., Gibb, T. S., McGuire, A. L., Wolpe, P. R., Wynia, M. K., Applewhite, M. K., Caplan, A., Diekema, D. S., Hester, D. M., Lehmann, L. S., McLeod-Sordjan, R., Schiff, T., Tabor, H. K., Wieten, S. E., & Eberl, J. T. (2020). Ventilator triage policies during the COVID-19 pandemic at U.S. hospitals associated with members of the Association of Bioethics program directors. Annals of Internal Medicine, 173(3), 188–194. doi:10.7326/M20-1738.

Daugherty Biddison, E. L., Faden, R., Gwon, H. S., Mareiniss, D. P., Regenberg, A. C., Schoch-Spana, M., Schwartz, J., & Toner, E. S. (2019). Too Many Patients…A Framework to Guide Statewide Allocation of Scarce Mechanical Ventilation During Disasters. Chest, 155(4), 848–854. doi:10.1016/j.chest.2018.09.025.

Singer, P. A., & Mapa, J. (1998). Ethics of resource allocation: dimensions for healthcare executives. Hospital Quarterly, 1(4), 29–31. doi:10.12927/hcq..16567.

Solomon, M. Z., Wynia, M. K., & Gostin, L. O. (2020). Covid-19 Crisis Triage — Optimizing Health Outcomes and Disability Rights. New England Journal of Medicine, 383(5), e27. doi:10.1056/nejmp2008300.

Committe on Bioethics (DH-BIO). (2020). DH-BIO Statement on human rights considerations relevant to the COVID-19 pandemic. Available online: (accessed on December 2021).

International Bioethics Committee (IBC). (2020). Statement on COVID-19: Ethical Considerations From a Global Perspective, Statement of the UNESCO International Bioethics Committee (IBC) and the UNESCO World Commission on the Ethics of Scientific Knowledge and Technology (COMEST), 1–4, Paris, France. Available online: (accessed on December 2021).

Vaidya, O. S., & Kumar, S. (2006). Analytic hierarchy process: An overview of applications. European Journal of Operational Research, 169(1), 1–29. doi:10.1016/j.ejor.2004.04.028.

Sprung, C. L., Woodcock, T., Sjokvist, P., Ricou, B., Bulow, H. H., Lippert, A., Maia, P., Cohen, S., Baras, M., Hovilehto, S., Ledoux, D., Phelan, D., Wennberg, E., & Schobersberger, W. (2008). Reasons, considerations, difficulties and documentation of end-of-life decisions in European intensive care units: The ETHICUS Study. Intensive Care Medicine, 34(2), 271–277. doi:10.1007/s00134-007-0927-1.

Cesari, M., & Proietti, M. (2020). COVID-19 in Italy: Ageism and Decision Making in a Pandemic. Journal of the American Medical Directors Association, 21(5), 576–577. doi:10.1016/j.jamda.2020.03.025.

Rosenbaum, L. (2020). Facing COVID-19 in Italy - Ethics, logistics, and therapeutics on the epidemic’s front line. Recenti Progressi in Medicina, 111(4), 192–197. doi:10.1701/3347.33179.

Truog, R. D., Mitchell, C., & Daley, G. Q. (2020). The Toughest Triage — Allocating Ventilators in a Pandemic. New England Journal of Medicine, 382(21), 1973–1975. doi:10.1056/nejmp2005689.

McCullough, L. B., Coverdale, J. H., & Chervenak, F. A. (2007). Constructing a systematic review for argument-based clinical ethics literature: The example of concealed medications. Journal of Medicine and Philosophy, 32(1), 65–76. doi:10.1080/03605310601152206.

McDougall, R. (2014). Systematic reviews in bioethics: Types, challenges, and value. Journal of Medicine and Philosophy (United Kingdom), 39(1), 89–97. doi:10.1093/jmp/jht059.

Angelos, P. (2020). Surgeons, Ethics, and COVID-19: Early Lessons Learned. Journal of the American College of Surgeons, 230(6), 1119–1120. doi:10.1016/j.jamcollsurg.2020.03.028.

Auriemma, C. L., Molinero, A. M., Houtrow, A. J., Persad, G., White, D. B., & Halpern, S. D. (2020). Eliminating Categorical Exclusion Criteria in Crisis Standards of Care Frameworks. American Journal of Bioethics, 20(7), 28–36. doi:10.1080/15265161.2020.1764141.

Jeffrey, D. I. (2020). Relational ethical approaches to the COVID-19 pandemic. Journal of Medical Ethics, 46(8), 495–498. doi:10.1136/medethics-2020-106264.

Escher, M., Cullati, S., Hudelson, P., Nendaz, M., Ricou, B., Perneger, T., & Dayer, P. (2019). Admission to intensive care: A qualitative study of triage and its determinants. Health Services Research, 54(2), 474–483. doi:10.1111/1475-6773.13076.

Mannelli, C., & Mannelli, C. (2020). Whose life to save? Scarce resources allocation in the COVID-19 outbreak. Journal of Medical Ethics, 46(6), 364–366. doi:10.1136/medethics-2020-106227.

Jöbges, S., Vinay, R., Luyckx, V. A., & Biller-Andorno, N. (2020). Recommendations on COVID-19 triage: international comparison and ethical analysis. Bioethics, 34(9), 948–959. doi:10.1111/bioe.12805.

Robert, R., Kentish-Barnes, N., Boyer, A., Laurent, A., Azoulay, E., & Reignier, J. (2020). Ethical dilemmas due to the Covid-19 pandemic. Annals of Intensive Care, 10(1). doi:10.1186/s13613-020-00702-7.

Lai, J., Ma, S., Wang, Y., Cai, Z., Hu, J., Wei, N., Wu, J., Du, H., Chen, T., Li, R., Tan, H., Kang, L., Yao, L., Huang, M., Wang, H., Wang, G., Liu, Z., & Hu, S. (2020). Factors associated with mental health outcomes among health care workers exposed to coronavirus disease 2019. JAMA Network Open, 3(3). doi:10.1001/jamanetworkopen.2020.3976.

Raith, E. P., Udy, A. A., Bailey, M., McGloughlin, S., MacIsaac, C., Bellomo, R., & Pilcher, D. V. (2017). Prognostic accuracy of the SOFA score, SIRS criteria, and qSOFA score for in-hospital mortality among adults with suspected in.fection admitted to the intensive care unit. Jama, 317(3), 290-300. doi: 0.1001/jama.2016.20328.

Herreros, B., Gella, P., & Real De Asua, Di. (2020). Triage during the COVID-19 epidemic in Spain: Better and worse ethical arguments. Journal of Medical Ethics, 46(7), 455–458. doi:10.1136/medethics-2020-106352.

Aziz, S., Arabi, Y. M., Alhazzani, W., Evans, L., Citerio, G., Fischkoff, K., ... & Christian, M. D. (2020). Managing ICU surge during the COVID-19 crisis: rapid guidelines. Intensive care medicine, 46(7), 1303-1325. doi: 10.1007/s00134-020-06092-5

Hulsbergen, A. F. C., Eijkholt, M. M., Balak, N., Brennum, J., Bolger, C., Bohrer, A. M., Feldman, Z., Holsgrove, D., Kitchen, N., Mathiesen, T. I., Moojen, W. A., Samprón, N., Sames, M., Sandvik, U., Tisell, M., & Broekman, M. L. D. (2020). Ethical triage during the COVID-19 pandemic: a toolkit for neurosurgical resource allocation. Acta Neurochirurgica, 162(7), 1485–1490. doi:10.1007/s00701-020-04375-w.

Mohammed, K. I., Zaidan, A. A., Zaidan, B. B., Albahri, O. S., Alsalem, M. A., Albahri, A. S., Hadi, A., & Hashim, M. (2019). Real-Time Remote-Health Monitoring Systems: a Review on Patients Prioritisation for Multiple-Chronic Diseases, Taxonomy Analysis, Concerns and Solution Procedure. Journal of Medical Systems, 43(7). doi:10.1007/s10916-019-1362-x.

Kalid, N., Zaidan, A. A., Zaidan, B. B., Salman, O. H., Hashim, M., Albahri, O. S., & Albahri, A. S. (2018). Based on Real Time Remote Health Monitoring Systems: A New Approach for Prioritization “Large Scales Data” Patients with Chronic Heart Diseases Using Body Sensors and Communication Technology. Journal of Medical Systems, 42(4). doi:10.1007/s10916-018-0916-7.

Samanlioglu, F., & Kaya, B. E. (2020). Evaluation of the COVID-19 Pandemic Intervention Strategies with Hesitant F-AHP. Journal of Healthcare Engineering, 2020, 1–11. doi:10.1155/2020/8835258.

Vinay, R., Baumann, H., & Biller-Andorno, N. (2021). Ethics of ICU triage during COVID-19. British Medical Bulletin, 138(1), 5–15. doi:10.1093/bmb/ldab009.

Camporesi, S., & Mori, M. (2021). Ethicists, doctors and triage decisions: Who should decide? And on what basis? Journal of Medical Ethics, 47(12), E18. doi:10.1136/medethics-2020-106499.

Ijzerman, M. J., Van Til, J. A., & Bridges, J. F. P. (2012). A comparison of analytic hierarchy process and conjoint analysis methods in assessing treatment alternatives for stroke rehabilitation. Patient, 5(1), 45–56. doi:10.2165/11587140-000000000-00000.

Goepel, K. D. (2018). Implementation of an Online Software Tool for the Analytic Hierarchy Process (AHP-OS). International Journal of the Analytic Hierarchy Process, 10(3). doi:10.13033/ijahp.v10i3.590.

Maruthur, N. M., Joy, S. M., Dolan, J. G., Shihab, H. M., & Singh, S. (2015). Use of the analytic hierarchy process for medication decision-making in type 2 diabetes. PLoS ONE, 10(5). doi:10.1371/journal.pone.0126625.

Singh, R., & Avikal, S. (2020). COVID-19: A decision-making approach for prioritization of preventive activities. International Journal of Healthcare Management, 13(3), 257–262. doi:10.1080/20479700.2020.1782661.

Vargas, L. G. (1990). An overview of the analytic hierarchy process and its applications. European journal of operational research, 48(1), 2-8. doi: 10.1016/0377-2217(90)90056-H.

Wollmann, D., Steiner, M. T. A., Vieira, G. E., & Steiner, P. A. (2012). Avaliação de operadoras de saúde por usuários pelo método Analytic Hierarchy Process. Revista de Saude Publica, 46(5), 777–783. doi:10.1590/S0034-89102012000500003.

Shaikh, F. S., Aldhafferi, N., Buker, A., Alqahtani, A., Dey, S., Abdulhamid, S., Albuhairi, D. A. M., Alkabour, R. S. A., Atiyah, W. S. O., Chrouf, S. B., Alshehri, A., Olatunji, S. O., Almuhaideb, A. M., Alshahrani, M. S., Almunsour, Y., & Abdul-Salam, V. B. (2021). Comorbidities and risk factors for severe outcomes in covid-19 patients in saudi arabia: A retrospective cohort study. Journal of Multidisciplinary Healthcare, 14, 2169–2183. doi:10.2147/JMDH.S317884.

Pecchia, L., Bath, P. A., Pendleton, N., & Bracale, M. (2011). Analytic Hierarchy Process (AHP) for examining healthcare professionals’ assessments of risk factors: The relative importance of risk factors for falls in community-dwelling older people. Methods of Information in Medicine, 50(5), 435–444. doi:10.3414/ME10-01-0028.

Saaty, T. L. (1977). A scaling method for priorities in hierarchical structures. Journal of Mathematical Psychology, 15(3), 234–281. doi:10.1016/0022-2496(77)90033-5.

Saaty, T. L. (1986). Axiomatic foundation of the analytic hierarchy process. Management science, 32(7), 841-855. doi: 10.1287/mnsc.32.7.841.

Bozóki, S., & Rapcsák, T. (2008). On Saaty’s and Koczkodaj’s inconsistencies of pairwise comparison matrices. Journal of Global Optimization, 42(2), 157–175. doi:10.1007/s10898-007-9236-z.

Bozóki, S., Fülöp, J., & Koczkodaj, W. W. (2011). An LP-based inconsistency monitoring of pairwise comparison matrices. Mathematical and Computer Modelling, 54(1–2), 789–793. doi:10.1016/j.mcm.2011.03.026.

Herman, M. W., & Koczkodaj, W. W. (1994). APL2 implementation of a new definition of consistency of pairwise comparisons. ACM SIGAPL APL Quote Quad, 24(4), 37-40. doi: 10.1145/181921.181932.

Koczkodaj, W. W. (1993). A new definition of consistency of pairwise comparisons. Mathematical and Computer Modelling, 18(7), 79–84. doi:10.1016/0895-7177(93)90059-8.

Ho, W. (2008). Integrated analytic hierarchy process and its applications - A literature review. European Journal of Operational Research, 186(1), 211–228. doi:10.1016/j.ejor.2007.01.004.

Forman, E. H., & Selly, M. A. (2001). Decision by objectives: how to convince others that you are right. World Scientific. doi: 10.1142/4281.

Jost, L. (2006). Jost, L. Entropy and diversity. Oikos. Oikos, 113(2), 363–375. John Wiley & Sons. doi:10.1111/j.2006.0030-1299.14714.x

Issa, U. H., Balabel, A., Abdelhakeem, M., & Osman, M. M. A. (2021). Developing a risk model for assessment and control of the spread of covid-19. Risks, 9(2), 1–15. doi:10.3390/risks9020038.

World Health Organization. (2020). Algorithm for COVID-19 triage and referral: patient triage and referral for resource-limited settings during community transmission (No. WPR/DSE/2020/009). Manila: WHO Regional Office for the Western Pacific.

Centers for Disease Control and Prevention (CDC). (2021). Standard Operating Procedure ( SOP ) for Triage of Suspected COVID-19 Patients in non-US Healthcare Settings: Early Identification and Prevention of Transmission during Triage. Centres for Disease Control and Prevention, 2(October), 1–5. Available online: (accessed on December 2021).

Jänig, C., Forklage, R., Gurney, J. M., Groth, R., Wirth, C., van de Krol, H., Schmidbauer, W., & Güsgen, C. (2021). Triage Decisions in the Context of COVID-19: Old Burden, New Challenge-The Structured Approach for Intensive Care Unit Triage (SAINT) Protocol. Military Medicine, 186(3–4), e300–e304. doi:10.1093/milmed/usaa287.

Turcato, G., Zaboli, A., & Pfeifer, N. (2020). The COVID-19 epidemic and reorganisation of triage, an observational study. Internal and Emergency Medicine, 15(8), 1517–1524. doi:10.1007/s11739-020-02465-2.

Aull-Hyde, R., Erdogan, S., & Duke, J. M. (2006). An experiment on the consistency of aggregated comparison matrices in AHP. European Journal of Operational Research, 171(1), 290–295. doi:10.1016/j.ejor.2004.06.037.

Full Text: PDF

DOI: 10.28991/esj-2022-SPER-07


  • There are currently no refbacks.

Copyright (c) 2021 S A