Factors Influencing Triage Decisions in Patients Referred for ICU Admission

Abstract

BackgroundFew data is available on triage of critically ill patients. Because the demand for ICU beds often exceeds their availability, frequently intensivists need to triage these patients in order to equally and efficiently distribute the available resources based on the concept of potential benefit and reasonable chance of recovery. The objective of this study is to evaluate factors influencing triage decisions among patients referred for ICU admission and to assess its impact in outcome.MethodsA single-center, prospective, observational study of 165 consecutive triage evaluations was conducted in patients referred for ICU admission that were either accepted, or refused and treated on the medical or surgical wards as well as the step-down and telemetry units.ResultsSeventy-one patients (43.0%) were accepted for ICU admission. Mean Acute Physiology and Chronic Health Evaluation (APACHE)-II score was 15.3 (0 - 36) and 13.9 (0 - 30) for accepted and refused patients, respectively. Three patients (4.2%) had active advance directives on admission to ICU. Age, gender, and number of ICU beds available at the time of evaluation were not associated with triage decisions. Thirteen patients (18.3%) died in ICU, while the in-hospital mortality for refused patients was 12.8%.ConclusionRefusal of admission to ICU is common, although patients in which ICU admission is granted have higher mortality. Presence of active advance directives seems to play an important role in the triage decision process. Further efforts are needed to define which patients are most likely to benefit from ICU admission. Triage protocols or guidelines to promote efficient critical care beds use are warranted.

Triage decisions for ICU admission: Report from the Task Force of the World Federation of Societies of Intensive and Critical Care Medicine

“…Extremely ill patients with little chance of survival despite ICU admission are unlikely to benefit from transfer to the ICU; on the other hand, patients requiring anticipatory monitoring who will almost certainly thrive even if they are not admitted are also unlikely to benefit from ICU admission. Nevertheless, it can be extremely difficult to predict whether patients will thrive with or without ICU care (7,8). Considering the limited number of ICU beds, the indications for admission should be defined to enable the identification of patients who are most likely to benefit from intensive care.…”

Medical futility treatment in intensive care units

“…After taking into account that a part of those funds was spent on medical futility treatments, on patients that should not be treated in the ICU at all, it is clear that this is a significant financial consideration. By treating in the ICU patients that cannot benefit from that treatment, other patients who may benefit from intensive care may be refused such treatment (1). Considering that ICUs are usually of limited capacities and often fully booked, from a medical, ethical and economical point of view it is not justified to use it for medical futility treatments (1).…”

“…By treating in the ICU patients that cannot benefit from that treatment, other patients who may benefit from intensive care may be refused such treatment (1). Considering that ICUs are usually of limited capacities and often fully booked, from a medical, ethical and economical point of view it is not justified to use it for medical futility treatments (1).…”

“…With expert and aggressive treatment, a patient's life may be saved, disability reduced and a patient may fully recover (1). There are different ICUs -general, surgical, infectious diseases, internal medicine, cardiac, gastrointestinal, pediatric, psychiatric, neurological, trauma, etc.…”

“…To avoid medical futility treatment in ICUs, palliative care unit needs to be established, as well as protocols for determining medical futility cases and ethical committee that will decide which patients will be transferred to palliative care. presents with disease and injury, the main goal is to help the ill (1,5). Emphasis should be on maintaining and, if possible, enhancing patients' quality of life and, at the same time, reducing physical and emotional pain and suffering (5,6).…”