Intensive Care Unit Triage Decisions Research Articles

Causes and Outcomes of Intensive Care Admission Refusals: A Retrospective Audit from a Rural Teaching Hospital in Eastern Cape, South Africa.

(1) Background: Patients who deserve intensive care unit (ICU) admission may be denied due to a lack of resources, complicating ICU triage decisions for intensive care unit (ICU) clinicians. Among the resources that may be unavailable are trained personnel and monitored beds. In South Africa, the distribution of healthcare resources is reflected in the availability of ICU beds, with more ICU beds available in more affluent areas. Data on ICU refusal rates, reasons for refusal, patient characteristics, and outcomes are scarce in resource-constrained rural settings. Hence, this study sheds light on the ICU refusal rates, reasons for refusal, characteristics, and outcomes of refused patients at NMAH. (2) Methods: This was a three-month retrospective cross-sectional record review of refused and admitted patients from January to March 2022. COVID-19 patients and those younger than 13 years old were excluded. Refusal rates, reasons for refusal, characteristics, and outcomes of refused patients were analysed quantitatively using SPSS VS 20 software. Reasons for refusal were categorised as "too well", "too sick", and "suitable for admission but no resources". (3) Results: A total of 135 patients were discussed for ICU admission at NMAH during the study period; 73 (54.07%) were refused admission, and 62 (45.92%) were admitted. Being considered too sick to benefit from ICU was the most common reason for refusal (53.23%). Too well and no resources contributed 27.42% and 19.35%, respectively. Patients with poor functional status, comorbidities, medical diagnoses, and those referred from the ward or accident and emergency unit rather than the operating room were more likely to be refused ICU admission. Refused patients had a seven-day mortality rate of 47%. (4) Conclusions and recommendations: The study found an unmet need for critical care services at our institution, as well as a need for tools to help clinicians make objective triage decisions for critically ill patients. Therefore, the study suggests a need to improve the quality of services provided outside of the ICU, particularly for patients who were refused ICU admission, to improve their outcomes.

Outcome of cancer patients considered for intensive care unit admission in two university hospitals in the Netherlands: the danger of delayed ICU admissions and off-hour triage decisions

BackgroundVery few studies assessed the association between Intensive Care Unit (ICU) triage decisions and mortality. The aim of this study was to assess whether an association could be found between 30-day mortality, and ICU admission consultation conditions and triage decisions.MethodsWe conducted a retrospective cohort study in two large referral university hospitals in the Netherlands. We identified all adult cancer patients for whom ICU admission was requested from 2016 to 2019. Via a multivariable logistic regression analysis, we assessed the association between 30-day mortality, and ICU admission consultation conditions and triage decisions.ResultsOf the 780 cancer patients for whom ICU admission was requested, 332 patients (42.6%) were considered ‘too well to benefit’ from ICU admission, 382 (49%) patients were immediately admitted to the ICU and 66 patients (8.4%) were considered ‘too sick to benefit’ according to the consulting intensivist(s). The 30-day mortality in these subgroups was 30.1%, 36.9% and 81.8%, respectively. In the patient group considered ‘too well to benefit’, 258 patients were never admitted to the ICU and 74 patients (9.5% of the overall study population, 22.3% of the patients ‘too well to benefit’) were admitted to the ICU after a second ICU admission request (delayed ICU admission). Thirty-day mortality in these groups was 25.6% and 45.9%. After adjustment for confounders, ICU consultations during off-hours (OR 1.61, 95% CI 1.09–2.38, p-value 0.02) and delayed ICU admission (OR 1.83, 95% CI 1.00–3.33, p-value 0.048 compared to “ICU admission”) were independently associated with 30-day mortality.ConclusionThe ICU denial rate in our study was high (51%). Sixty percent of the ICU triage decisions in cancer patients were made during off-hours, and 22.3% of the patients initially considered “too well to benefit” from ICU admission were subsequently admitted to the ICU. Both decisions during off-hours and a delayed ICU admission were associated with an increased risk of death at 30 days. Our study suggests that in cancer patients, ICU triage decisions should be discussed during on-hours, and ICU admission policy should be broadened, with a lower admission threshold for critically ill cancer patients.

Decision-making in the ICU: An analysis of the ICU admission decision-making process using a '20 Questions' approach.

Deciding to admit a patient into the intensive care unit (ICU) is a high-stakes, high-stress, time-sensitive process. Elucidating the complexities of these decisions can contribute to a more efficient, effective process. To explore physicians' strategic thought processes in ICU triage decisions and identify important factors. Practitioners (N=29) were asked to decide on ICU referrals of two hypothetic cases using a modified '20 Questions' approach. Demographic data, decisions when full information was available, feedback on questions, rating of factors previously identified as important and influence of faith and personality traits were explored. Of the 735 questions asked, 95.92% were patient related. There were no significant differences in interview variables between the two cases or with regard to presentation order. The overall acceptance rate was 68.96%. Refusals were associated with longer interview times (p=0.014), as were lower ICU bed capacity (p=0.036), advancing age of the practitioner (p=0.040) and a higher faith score (p=0.004). Faith score correlated positively with the number of questions asked (p=0.028). There were no significant correlations with personality trait stanines. When full information was available, acceptances for Case A decreased (p=0.003) but increased for Case B (p=0.026). The net reclassification improvement index was -0.138 (p=0.248). Non-subspecialists were more likely to change their decisions (p=0.036). Limiting information to what is considered vital by using a '20 Questions' approach and allowing the receiving practitioner to create the decision frame may assist with ICU admission decisions. Practitioners should consider the metacognitive elements of their decision-making. The study used a novel approach to explore physicians' decision-making process for admitting a patient to the intensive care unit (ICU). Understanding the main factors that influence the decision-making process will allow for streamlining the referral process, more effective selection of patients most likely to benefit from ICU treatment, and prevent inappropriate admissions into the ICU. The findings can also help to improve data capture tools and encourage practitioners to critically reflect on their decision-making processes.

Triage and Ongoing Care for Critically Ill Patients in the Emergency Department: Results from a National Survey of Emergency Physicians.

IntroductionWe conducted a cross-sectional study at the Icahn School of Medicine at Mount Sinai to elicit emergency physician (EP) perceptions regarding intensive care unit (ICU) triage decisions and ongoing management for boarding of ICU patients in the emergency department (ED). We assessed factors influencing the disposition decision for critically ill patients in the ED to characterize EPs’ perceptions about ongoing critical care delivery in the ED while awaiting ICU admission.MethodsThrough content expert review and pilot testing, we iteratively developed a 25-item written survey targeted to EPs, eliciting current ICU triage structure, opinions on factors influencing ICU admission decisions, and views on caring for critically ill patients “boarding” in the ED for >4–6 hours.ResultsWe approached 732 EPs at a large, national emergency medicine conference, achieving 93.6% response and completion rate, with 54% academic and 46% community participants. One-fifth reported having formal ICU admission criteria, although only 36.6% reported adherence. Common factors influencing EPs’ ICU triage decisions were illness severity (91.1%), ICU interventions needed (87.6%), and diagnosis (68.2%), while ICU bed availability (13.5%) and presence of other critically ill patients in ED (10.2%) were less or not important. While 72.1% reported frequently caring for ICU boarders, respondents identified high patient volume (61.3%) and inadequate support staffing (48.6%) as the most common challenges in caring for boarding ICU patients.ConclusionPatient factors (eg, diagnosis, illness severity) were seen as more important than system factors (eg, bed availability) in triaging ED patients to the ICU. Boarding ICU patients is a common challenge for more than two-thirds of EPs, exacerbated by ED volume and staffing constraints.

In Between the Intensive Care Unit and the Ward.

The number of intensive care unit (ICU) beds in the United Stateshascontinuedto increaseover the last3decades, ashave ICU utilization rates and costs,1,2 and this despite the lack of any federal, regional, or critical care society mandates to justify these increases. Some experts believe that the increase in the number of ICU beds has led to inappropriate use of these beds by patients who are either too healthy or too sick to benefit from intensive care.3,4 This may in part explain the stable national ICU occupancy rate of approximately68%between 1985and2010 and suggests that ICU utilization has simply risen tomeet the increased number of beds.1,2 Furthermore, it hasbeenover adecadeandahalf sincenational societyguidelines for ICUand intermediate careunit admission, discharge, and triagewere published.5,6 In the intervening years, changes have occurred in the demographic and other characteristics of ICUpatientpopulations; the ICUworkforce has evolved; the legislative landscape has altered; and newethical and end-of-life factors have been introduced that affect the appropriate utilization of ICU beds. Ideally, US hospitals and ICUs would follow some consistent and clinically appropriate approaches to the triage of sick patients. At a minimum, we would expect that triage would be similar for day andnight,weekdayandweekendwithin the same hospital or hospital network, andwewould expect it to be independent of ICU and hospital occupancy rates. The reality, however, is far more complex and confusing: ICU triage decisions are based on many factors, some quantifiable and others intangible. These factors can be classified into 2 categories:hospital (institutional)basedandICUrelated.Hospitalbased factors include size (small,medium, or large), teaching or nonteaching status, nurse to patient ratios, rules and regulations of the limits ofward-based care, attitudes toward risk, practice styles of physicians andnurses, availability of nurses andsupport staff (eg,hospitalists, advancepractitioners, rapid response teams), privileging of clinicians for ICU admission, and the presence of step-down units (ie, intermediate or progressive). The ICU-based parameters include ICU to hospital bed ratios, model of care (ie, open, closed, or collaborative), types (ie, multiple-specialty ICUs or single, large ICU), intensivist staffing (ie, high or low intensity, full time or part time), presence of resident trainees and/or advance care practitioners, and coverage (ie, in-house or telemedicine). In this issueofJAMAInternalMedicine,ChangandShapiro7 retrospectively analyze ICU utilization for 4 medical conditions (diabetic ketoacidosis, pulmonary embolism,upper gastrointestinalbleeding,andcongestiveheart failure) in94acutecare nonfederal hospitals in Washington state and Maryland between2010and2012. These common illnessesmaybe classified as “in-between” conditions if they are not presenting at extreme levels of severity. The authors found great variability in the ICU utilization between high and low ICU utilizers. Higher ICUutilizationoccurred in smallerhospitals and teaching hospitals. Of note, the vast majority of hospitals had concordant ICU utilization (high or low) for all 4 conditions, suggesting consistent ICU vs ward triage patterns. The ICU and hospital occupancy did not affect ICU utilization for each of these conditions. Similarly, risk-adjustedhospitalmortality (at 30 days) did not differ between the high and low ICU utilizers;however, onceapatientwasadmitted to the ICU, therewas an increase in the number of invasive procedures (eg, central venous catheters) and higher hospital costs compared with patients cared for on the wards. Although this study showed greater use of standardized care pathways (represented by invasive procedures and increased costs) in the higher ICUutilization centers than in the lower, outcomes were similar. Many factors influence hospiAuthor Audio Interview at jamainternalmedicine.com

Development of an algorithm to aid triage decisions for intensive care unit admission: a clinical vignette and retrospective cohort study.

BackgroundIntensive care unit (ICU) admission triage is performed routinely and is often based solely on clinical judgment, which could mask biases. A computerized algorithm to aid ICU triage decisions was developed to classify patients into the Society of Critical Care Medicine’s prioritization system. In this study, we sought to evaluate the reliability and validity of this algorithm.MethodsNine senior physicians evaluated forty clinical vignettes based on real patients. The reference standard was defined as the priorities ascribed by two investigators with full access to patients’ records. Agreement of algorithm-based priorities with the reference standard and with intuitive priorities provided by the physicians were evaluated. Correlations between algorithm prioritization and physicians’ judgment of the appropriateness of ICU admissions in scarcity and nonscarcity settings were also evaluated. Validity was further assessed by retrospectively applying this algorithm to 603 patients with requests for ICU admission for association with clinical outcomes.ResultsAgreement between algorithm-based priorities and the reference standard was substantial, with a median κ of 0.72 (interquartile range [IQR] 0.52–0.77). Algorithm-based priorities demonstrated higher interrater reliability (overall κ 0.61, 95 % confidence interval [CI] 0.57–0.65; median percentage agreement 0.64, IQR 0.59–0.70) than physicians’ intuitive prioritization (overall κ 0.51, 95 % CI 0.47–0.55; median percentage agreement 0.49, IQR 0.44–0.56) (p = 0.001). Algorithm-based priorities were also associated with physicians’ judgment of appropriateness of ICU admission (priorities 1, 2, 3, and 4 vignettes would be admitted to the last ICU bed in 83.7 %, 61.2 %, 45.2 %, and 16.8 % of the scenarios, respectively; p < 0.001) and with actual ICU admission, palliative care consultation, and hospital mortality in the retrospective cohort.ConclusionsThis ICU admission triage algorithm demonstrated good reliability and validity. However, more studies are needed to evaluate a difference in benefit of ICU admission justifying the admission of one priority stratum over the others.Electronic supplementary materialThe online version of this article (doi:10.1186/s13054-016-1262-0) contains supplementary material, which is available to authorized users.

The Eldicus prospective, observational study of triage decision making in European intensive care units. Part II

Life and death triage decisions are made daily by intensive care unit physicians. Admission to an intensive care unit is denied when intensive care unit resources are constrained, especially for the elderly. To determine the effect of intensive care unit triage decisions on mortality and intensive care unit benefit, specifically for elderly patients. Prospective, observational study of triage decisions from September 2003 until March 2005. Eleven intensive care units in seven European countries. All patients >18 yrs with an explicit request for intensive care unit admission. Admission or rejection to intensive care unit. Demographic, clinical, hospital, physiologic variables, and 28-day mortality were obtained on consecutive patients. There were 8,472 triages in 6,796 patients, 5,602 (82%) were accepted to the intensive care unit, 1,194 (18%) rejected; 3,795 (49%) were ≥ 65 yrs. Refusal rate increased with increasing patient age (18-44: 11%; 45-64: 15%; 65-74: 18%; 75-84: 23%; >84: 36%). Mortality was higher for older patients (18-44: 11%; 45-64: 21%; 65-74: 29%; 75-84: 37%; >84: 48%). Differences between mortalities of accepted vs. rejected patients, however, were greatest for older patients (18-44: 10.2% vs. 12.5%; 45-64: 21.2% vs. 22.3%; 65-74: 27.9% vs. 34.6%; 75-84: 35.5% vs. 40.4%; >84: 41.5% vs. 58.5%). Logistic regression showed a greater mortality reduction for accepted vs. rejected patients corrected for disease severity for elderly patients (age >65 [odds ratio 0.65, 95% confidence interval 0.55-0.78, p < .0001]) than younger patients (age <65 [odds ratio 0.74, 95% confidence interval 0.57-0.97, p = .01]). Despite the fact that elderly patients have more intensive care unit rejections than younger patients and have a higher mortality when admitted, the mortality benefit appears greater for the elderly. Physicians should consider changing their intensive care unit triage practices for the elderly.

Implications of ICU triage decisions on patient mortality: a cost-effectiveness analysis

IntroductionIntensive care is generally regarded as expensive, and as a result beds are limited. This has raised serious questions about rationing when there are insufficient beds for all those referred. However, the evidence for the cost effectiveness of intensive care is weak and the work that does exist usually assumes that those who are not admitted do not survive, which is not always the case. Randomised studies of the effectiveness of intensive care are difficult to justify on ethical grounds; therefore, this observational study examined the cost effectiveness of ICU admission by comparing patients who were accepted into ICU after ICU triage to those who were not accepted, while attempting to adjust such comparison for confounding factors.MethodsThis multi-centre observational cohort study involved 11 hospitals in 7 EU countries and was designed to assess the cost effectiveness of admission to intensive care after ICU triage. A total of 7,659 consecutive patients referred to the intensive care unit (ICU) were divided into those accepted for admission and those not accepted. The two groups were compared in terms of cost and mortality using multilevel regression models to account for differences across centres, and after adjusting for age, Karnofsky score and indication for ICU admission. The analyses were also stratified by categories of Simplified Acute Physiology Score (SAPS) II predicted mortality (< 5%, 5% to 40% and >40%). Cost effectiveness was evaluated as cost per life saved and cost per life-year saved.ResultsAdmission to ICU produced a relative reduction in mortality risk, expressed as odds ratio, of 0.70 (0.52 to 0.94) at 28 days. When stratified by predicted mortality, the odds ratio was 1.49 (0.79 to 2.81), 0.7 (0.51 to 0.97) and 0.55 (0.37 to 0.83) for <5%, 5% to 40% and >40% predicted mortality, respectively. Average cost per life saved for all patients was $103,771 (€82,358) and cost per life-year saved was $7,065 (€5,607). These figures decreased substantially for patients with predicted mortality higher than 40%, $60,046 (€47,656) and $4,088 (€3,244), respectively. Results were very similar when considering three-month mortality. Sensitivity analyses performed to assess the robustness of the results provided findings similar to the main analyses.ConclusionsNot only does ICU appear to produce an improvement in survival, but the cost per life saved falls for patients with greater severity of illness. This suggests that intensive care is similarly cost effective to other therapies that are generally regarded as essential.

Should Age Limit Admission to the Intensive Care Unit?

People who are older than 65 years of age are the fastest growing segment of the United States population. With the projected exponential increase in the number of elderly patients and the increasing burden of chronic disease, the number of elderly patients who will require treatment in an intensive care unit is expected to increase. Owing to the elderly patient's reduced life expectancy and higher intensive care unit and hospital mortality, it could be argued that elderly patients should not be admitted to the intensive care unit. However, an analysis of available data suggests that functional elderly patients have a favorable "long-term" outcome after intensive care unit admission. This suggests that age alone should not be used in making intensive care unit triage decisions.

Survival of critically ill patients hospitalized in and out of intensive care*

A lack of intensive care units beds in Israel results in critically ill patients being treated outside of the intensive care unit. The survival of such patients is largely unknown. The present study's objective was to screen entire hospitals for newly deteriorated patients and compare their survival in and out of the intensive care unit. A priori developed intensive care unit admission criteria were used to screen, during 2 wks, the patient population for eligible incident patients. A screening team visited every hospital ward of five acute care hospitals daily. Eligible patients were identified among new admissions in the emergency department and among hospitalized patients who acutely deteriorated. Patients were followed for 30 days for mortality regardless of discharge. Five acute care hospitals. A total of 749 newly deteriorated patients. None. Crude survival of patients in and out of the intensive care unit was compared by Kaplan-Meier curves, and Cox models were constructed to adjust the survival comparisons for residual case-mix differences. A total of 749 newly deteriorated patients were identified among 44,000 patients screened (1.7%). Of these, 13% were admitted to intensive care unit, 32% to special care units, and 55% to regular departments. Intensive care unit patients had better early survival (0-3 days) relative to regular departments (p=.0001) in a Cox multivariate model. Early advantage of intensive care was most pronounced among patients who acutely deteriorated while on hospital wards rather than among newly admitted patients. Only a small proportion of eligible patients reach the intensive care unit, and early admission is imperative for their survival advantage. As intensive care unit benefit was most pronounced among those deteriorating on hospital wards, intensive care unit triage decisions should be targeted at maximizing intensive care unit benefit by early admitting patients deteriorating on hospital wards.

ICU care for patients with gastrointestinal bleeding: impact on cost and outcome

Objective: To examine the factors which identify patients with gastrointestinal bleeding (GIB) who benefit from intensive care unit (ICU) admission and the impact of ICU triage decisions on cost an...