Practices in Triage and Transfer of Critically Ill Patients: A Qualitative Systematic Review of Selection Criteria

Dahine, Joseph; Hébert, Paul C.; Ziegler, Daniela; Chenail, Noémie; Ferrari, Nicoletta; Hébert, Réjean

doi:10.1097/ccm.0000000000004624

Cited by 13 publications

(14 citation statements)

References 143 publications

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“…1 Many publications have developed and evaluated triage selection criteria, but there remains a significant knowledge gap and the final criteria are subject to socio-ethical debate. [2][3][4] Preferably, triage is averted, but when necessary, the decision should be guided by evidence-based medical criteria. Since March 2020, many studies have been published regarding the clinical characteristics of patients suffering from a SARS-CoV-2 infection in both smaller (n=58, 5 n=200 6 ) and larger cohorts (n>5000 [7][8][9] ).…”

Section: Open Accessmentioning

confidence: 99%

Predicting mortality of individual patients with COVID-19: a multicentre Dutch cohort

Ottenhoff

Ramos²,

Potters

et al. 2021

BMJ Open

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ObjectiveDevelop and validate models that predict mortality of patients diagnosed with COVID-19 admitted to the hospital.DesignRetrospective cohort study.SettingA multicentre cohort across 10 Dutch hospitals including patients from 27 February to 8 June 2020.ParticipantsSARS-CoV-2 positive patients (age ≥18) admitted to the hospital.Main outcome measures21-day all-cause mortality evaluated by the area under the receiver operator curve (AUC), sensitivity, specificity, positive predictive value and negative predictive value. The predictive value of age was explored by comparison with age-based rules used in practice and by excluding age from the analysis.Results2273 patients were included, of whom 516 had died or discharged to palliative care within 21 days after admission. Five feature sets, including premorbid, clinical presentation and laboratory and radiology values, were derived from 80 features. Additionally, an Analysis of Variance (ANOVA)-based data-driven feature selection selected the 10 features with the highest F values: age, number of home medications, urea nitrogen, lactate dehydrogenase, albumin, oxygen saturation (%), oxygen saturation is measured on room air, oxygen saturation is measured on oxygen therapy, blood gas pH and history of chronic cardiac disease. A linear logistic regression and non-linear tree-based gradient boosting algorithm fitted the data with an AUC of 0.81 (95% CI 0.77 to 0.85) and 0.82 (0.79 to 0.85), respectively, using the 10 selected features. Both models outperformed age-based decision rules used in practice (AUC of 0.69, 0.65 to 0.74 for age >70). Furthermore, performance remained stable when excluding age as predictor (AUC of 0.78, 0.75 to 0.81).ConclusionBoth models showed good performance and had better test characteristics than age-based decision rules, using 10 admission features readily available in Dutch hospitals. The models hold promise to aid decision-making during a hospital bed shortage.

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Section: Open Accessmentioning

confidence: 99%

Predicting mortality of individual patients with COVID-19: a multicentre Dutch cohort

Ottenhoff

Ramos²,

Potters

et al. 2021

BMJ Open

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“… 7 The lack of specific criteria for ICU admission decisions has been recently pointed out. 8 Whereas a decision supporting framework was developed to address the issue of limiting or not life-sustaining treatments in the ICU, 9 no such framework exists for triage. Yet, deciding whether to admit a patient to the ICU is often complex, and physicians mostly rely on their clinical judgement.…”

Section: Introductionmentioning

confidence: 99%

Physicians’ perspective on potentially non-beneficial treatment when assessing patients with advanced disease for ICU admission: a qualitative study

et al. 2021

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ObjectiveThe use of intensive care at the end of life can be high, leading to inappropriate healthcare utilisation, and prolonged suffering for patients and families. The objective of the study was to determine which factors influence physicians’ admission decisions in situations of potentially non-beneficial intensive care.DesignThis is a secondary analysis of a qualitative study exploring the triage process. In-depth interviews were analysed using an inductive approach to thematic content analysis.SettingData were collected in a Swiss tertiary care centre between March and June 2013.Participants12 intensive care unit (ICU) physicians and 12 internists routinely involved in ICU admission decisions.ResultsPhysicians struggled to understand the request for intensive care for patients with advanced disease and full code status. Physicians considered patients’ long-term vital and functional prognosis, but they also resorted to shortcuts, that is, a priori consensus about reasons for admitting a patient. Family pressure and unexpected critical events were determinants of admission to the ICU. Patient preferences, ICU physician’s expertise and collaborative decision making facilitated refusal. Physicians were willing to admit a patient with advanced disease for a limited amount of time to fulfil a personal need.ConclusionsIn situations of potentially non-beneficial intensive care, the influence of shortcuts or context-related factors suggests that practice variations and inappropriate admission decisions are likely to occur. Institutional guidelines and timely goals of care discussions with patients with advanced disease and their families could contribute to ensuring appropriate levels of care.

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“…The population understands some words, like "therapeutic obstinacy, " and in fact the idea is to use these words, but not everyone is really able to understand them." (Participant 4, age range [31][32][33][34][35][36][37][38][39][40] One participant added that the difficulty to address endof-life issues is also common among HCPs and not only family members: "Colleagues lack sensitivity on this. .…”

Section: Paternalism's Comebackmentioning

confidence: 99%

“…Think about how difficult this is to accept." (Participant 4, age range [31][32][33][34][35][36][37][38][39][40] Participants also reported that the absence of the family members, who could not be close to the patients in the hospital and frequently interact with the care team, accentuated this form of paternalism and prevented a shared decision making approach.…”

Section: Paternalism's Comebackmentioning

confidence: 99%

Physicians' Acceptance of Triage Guidelines in the Context of the COVID-19 Pandemic: A Qualitative Study

Merlo

Lepori

Malacrida³

et al. 2021

Front. Public Health

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Aims: One of the major ethical challenges posed by the Covid-19 pandemic comes in the form of fair triage decisions for critically ill patients in situations where life-saving resources are limited. In Spring 2020, the Swiss Academy of Medical Sciences (SAMS) issued specific guidelines on triage for intensive-care treatment in the context of the Covid-19 pandemic. While evidence has shown that the capacities of intensive care medicine throughout Switzerland were sufficient to take care of all critically ill patients during the first wave of the outbreak, no evidence is available regarding the acceptance of these guidelines by ICU staff. The aim of this qualitative study was to explore the acceptance and perceived implementation of the SAMS guidelines among a sample of senior physicians involved in the care of Covid-19 patients in the Canton of Ticino. Specific objectives included capturing and describing physicians' attitudes toward the guidelines, any challenges experienced in their application, and any perceived factors that facilitated or would facilitate their application.Methods: We conducted face-to-face and telephone interviews with a purposive sample of nine senior physicians employed as either head of unity, deputy-head of unit, or medical director in either one of the two Covid-19 hospitals in the Canton of Ticino during the peak of the outbreak. Interviews were transcribed verbatim and thematically analyzed using an inductive approach.Results: We found that participants held different views regarding the nature of the guidelines, saw decisions on admission as a matter of collective responsibility, argued that decisions should be based on a medical futility principle rather than an age criterion, and found that difficulties to address end-of-life issues led to a comeback of paternalism.Conclusions: Results highlight the importance of clarifying the nature of the guidelines, establishing authority, and responsibility during triaging decisions, recognizing and addressing sources of interference with patients' autonomy, and the need of a cultural shift in timely and efficiently addressing end-of-life issues.

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Practices in Triage and Transfer of Critically Ill Patients: A Qualitative Systematic Review of Selection Criteria

Abstract: Supplemental Digital Content is available in the text.

Cited by 13 publications

References 143 publications

Predicting mortality of individual patients with COVID-19: a multicentre Dutch cohort

Predicting mortality of individual patients with COVID-19: a multicentre Dutch cohort

Physicians’ perspective on potentially non-beneficial treatment when assessing patients with advanced disease for ICU admission: a qualitative study

Physicians' Acceptance of Triage Guidelines in the Context of the COVID-19 Pandemic: A Qualitative Study

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