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Triage of intensive care patients: identifying agreement and controversy.

ABSTRACT: RATIONALE:Intensive care unit (ICU) resources are limited in many hospitals. Patients with little likelihood of surviving are often admitted to ICUs. Others who might benefit from ICU are not admitted. OBJECTIVE:To provide an updated consensus statement on the principles and recommendations for the triage of patients for ICU beds. DESIGN:The previous Society of Critical Care Medicine (SCCM) consensus statement was used to develop drafts of general and specific principles and recommendations. Investigators and consultants were sent the statements and responded with their agreement or disagreement. SETTING:The Eldicus project (triage decision making for the elderly in European intensive care units). PARTICIPANTS:Eldicus investigators, consultants, and experts consisting of intensivists, users of ICU services, ethicists, administrators, and public policy officials. INTERVENTIONS:Consensus development was used to grade the statements and recommendations. MEASUREMENTS AND MAIN RESULTS:Consensus was defined as 80% agreement or more. Consensus was obtained for 54 (87%) of 62 statements including all (19) general principles, 31 (86%) of the specific principles, and 10 (71%) of the recommendations. Inconsistencies in responses were noted for ICU admission and discharge. Despite agreement for guidelines applying to individual patients and an objective triage score, there was no agreement for a survival cutoff for triage, not even for a chance of survival of 0.1%. CONCLUSIONS:Consensus was reached for most general and specific ICU triage principles and recommendations. Further debate and discussion should help resolve the remaining discrepancies.

SUBMITTER: Sprung CL

PROVIDER: S-EPMC5549951 | biostudies-literature | 2013 Nov

REPOSITORIES: biostudies-literature

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Triage of intensive care patients: identifying agreement and controversy.

Sprung Charles L CL Danis Marion M Iapichino Gaetano G Artigas Antonio A Kesecioglu Jozef J Moreno Rui R Lippert Anne A Curtis J Randall JR Meale Paula P Cohen Simon L SL Levy Mitchell M MM Truog Robert D RD

Intensive care medicine 20130808 11

<h4>Rationale</h4>Intensive care unit (ICU) resources are limited in many hospitals. Patients with little likelihood of surviving are often admitted to ICUs. Others who might benefit from ICU are not admitted.<h4>Objective</h4>To provide an updated consensus statement on the principles and recommendations for the triage of patients for ICU beds.<h4>Design</h4>The previous Society of Critical Care Medicine (SCCM) consensus statement was used to develop drafts of general and specific principles an ...[more]

PMID: 23925544

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Project description:BackgroundFor several decades, emergency departments (EDs) utilization has increased, inducing ED overcrowding in many countries. This phenomenon is related partly to an excessive number of nonurgent patients. To resolve ED overcrowding and to decrease nonurgent visits, the most common solution has been to triage the ED patients to identify potentially nonurgent patients, i.e. which could have been dealt with by general practitioner. The objective of this study was to measure agreement among ED health professionals on the urgency of an ED visit, and to determine if the level of agreement is consistent among different sub-groups based on following explicit criteria: age, medical status, type of referral to the ED, investigations performed in the ED, and the discharge from the ED.MethodsWe conducted a multicentric cross-sectional study to compare agreement between nurses and physicians on categorization of ED visits into urgent or nonurgent. Subgroups stratified by criteria characterizing the ED visit were analyzed in relation to the outcome of the visit.ResultsOf 1,928 ED patients, 350 were excluded because data were lacking. The overall nurse-physician agreement on categorization was moderate (kappa = 0.43). The levels of agreement within all subgroups were variable and low. The highest agreement concerned three subgroups of complaints: cranial injury (kappa = 0.61), gynaecological (kappa = 0.66) and toxicology complaints (kappa = 1.00). The lowest agreement concerned two subgroups: urinary-nephrology (kappa = 0.09) and hospitalization (kappa = 0.20). When categorization of ED visits into urgent or nonurgent cases was compared to hospitalization, ED physicians had higher sensitivity and specificity than nurses (respectively 94.9% versus 89.5%, and 43.1% versus 30.9%).ConclusionsThe lack of physician-nurse agreement and the inability to predict hospitalization have important implications for patient safety. When urgency screening is used to determine treatment priority, disagreement might not matter because all patients in the ED are seen and treated. But using assessments as the basis for refusal of care to potential nonurgent patients raises legal, ethical, and safety issues. Managed care organizations should be cautious when applying such criteria to restrict access to EDs.

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Triage of intensive care patients: identifying agreement and controversy.

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Triage of intensive care patients: identifying agreement and controversy.

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