Variability in triage practices for critically ill cancer patients: A randomized controlled trial

Rathi, Nisha; Haque, Sajid; Morales, Freddy; Kaul, Bhavika; Ramírez, Rafael; Ovu, Steven; Feng, Lei; Dong, Wenli; Price, Kristen; Ugarte, Sebastián; Raimondi, N.; Quintero, A.; Cardenas, Yenny; Nates, Joseph L.; Lacctin,; groups, Onccc-R-Net

doi:10.1016/j.jcrc.2019.05.012

Cited by 7 publications

(11 citation statements)

References 43 publications

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“…Among patient-and context-related factors, family preferences have been identified as significantly influencing admission decisions [1,24,28,29]. Pressure from family members belonged to the most common reasons given by intensivists for deviating from triage guidelines [27]. In our study, the best consensus was reached for family preferences, in particular for patients with advanced disease.…”

Section: Discussionmentioning

confidence: 72%

“…It could also be due to inter-individual differences in the appreciation of the various aspects of clinical situations, notwithstanding the medical specialty [23,24]. Similarly, low agreements were found among intensivists in an experimental study about the choice of life-sustaining treatments [25], and in two vignette-based studies about the benefit of ICU admission compared to care on the general ward [26] and about ICU admission for cancer patients [27]. The importance given to different determinants of admission decisions seems to vary among intensivists.…”

Section: Discussionmentioning

confidence: 99%

“…Of note, a time-limited admission to the ICU is an accepted strategy if the patient or family needs time to adapt [30]. Families can put so much pressure on physicians that patients are admitted to the ICU out of fear of litigation [1,27]. This raises the question of how appropriately the family plays the role of surrogate decision maker.…”

Section: Discussionmentioning

confidence: 99%

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Physicians’ Views and Agreement about Patient- and Context-Related Factors Influencing ICU Admission Decisions: A Prospective Study

Cullati

Perneger

Scherer

et al. 2021

JCM

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Background: Single patient- and context-related factors have been associated with admission decisions to intensive care. How physicians weigh various factors and integrate them into the decision-making process is not well known. Objectives: First, to determine which patient- and context-related factors influence admission decisions according to physicians, and their agreement about these determinants; and second, to examine whether there are differences for patients with and without advanced disease. Method: This study was conducted in one tertiary hospital. Consecutive ICU consultations for medical inpatients were prospectively included. Involved physicians, i.e., internists and intensivists, rated the importance of 13 factors for each decision on a Likert scale (1 = negligible to 5 = predominant). We cross-tabulated these factors by presence or absence of advanced disease and examined the degree of agreement between internists and intensivists using the kappa statistic. Results: Of 201 evaluated patients, 105 (52.2%) had an advanced disease, and 140 (69.7%) were admitted to intensive care. The mean number of important factors per decision was 3.5 (SD 2.4) for intensivists and 4.4 (SD 2.1) for internists. Patient’s comorbidities, quality of life, preferences, and code status were most often mentioned. Inter-rater agreement was low for the whole population and after stratifying for patients with and without advanced disease. Kappa values ranged from 0.02 to 0.34 for all the patients, from −0.05 to 0.42 for patients with advanced disease, and from −0.08 to 0.32 for patients without advanced disease. The best agreement was found for family preferences. Conclusion: Poor agreement between physicians about patient- and context-related determinants of ICU admission suggests a lack of explicitness during the decision-making process. The potential consequences are increased variability and inequity regarding which patients are admitted. Timely advance care planning involving families could help physicians make the decision most concordant with patient preferences.

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Section: Discussionmentioning

confidence: 72%

Section: Discussionmentioning

confidence: 99%

See 1 more Smart Citation

Physicians’ Views and Agreement about Patient- and Context-Related Factors Influencing ICU Admission Decisions: A Prospective Study

Cullati

Perneger

Scherer

et al. 2021

JCM

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“…31 Several aspects, including patient, system, and provider factors, affect initial triage decision making and warrant further exploration and research. [32][33][34] While this data is not available within our current dataset and is a limitation of this study, it presents an avenue for future research, where more granular aspects of factors influencing triage decisions, such as the number of waiting patients, available beds, functional status, reasoning behind initial rejection followed by acceptance of patient are considered. Not surprisingly, a lower severity of illness by log 10 MPM 0 -III was also predictive of delayed recognition, and was different between those with and without delayed recognition.…”

Section: Discussionmentioning

confidence: 99%

Predictors of Delayed Recognition of Critical Illness in Emergency Department Patients and Its Effect on Morbidity and Mortality

Goel

Durst

Vargas-Torres

et al. 2020

J Intensive Care Med

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Purpose: Timely recognition of critical illness is associated with improved outcomes, but is dependent on accurate triage, which is affected by system factors such as workload and staffing. We sought to first study the effect of delayed recognition on patient outcomes after controlling for system factors and then to identify potential predictors of delayed recognition. Methods: We conducted a retrospective cohort study of Emergency Department (ED) patients admitted to the Intensive Care Unit (ICU) directly from the ED or within 48 hours of ED departure. Cohort characteristics were obtained through electronic and standardized chart abstraction. Operational metrics to estimate ED workload and volume using census data were matched to patients’ ED stays. Delayed recognition of critical illness was defined as an absence of an ICU consult in the ED or declination of ICU admission by the ICU team. We employed entropy-balanced multivariate models to examine the association between delayed recognition and development of persistent organ dysfunction and/or death by hospitalization day 28 (POD+D), and multivariable regression modeling to identify factors associated with delayed recognition. Results: Increased POD+D was seen for those with delayed recognition (OR 1.82, 95% CI 1.13-2.92). When the delayed recognition was by the ICU team, the patient was 2.61 times more likely to experience POD+D compared to those for whom an ICU consult was requested and were accepted for admission. Lower initial severity of illness score (OR 0.26, 95% CI 0.12-0.53) was predictive of delayed recognition. The odds for delayed recognition decreased when ED workload is higher (OR 0.45, 95% CI 0.23-0.89) compared to times with lower ED workload. Conclusions: Increased POD+D is associated with delayed recognition. Patient and system factors such as severity of illness and ED workload influence the odds of delayed recognition of critical illness and need further exploration.

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“…Recognition of impending critical illness is challenging in all settings and may be more so among patients with cancer [121]. As an example, oncology patients frequently receive therapies which attenuate (e.g., glucocorticoids) or cause fevers (e.g., blood products), limiting both the sensitivity and specificity of the fever threshold to identify infected patients.…”

Section: Time Is Of the Essence: Facilitating Early Recognition And M...mentioning

confidence: 99%

Sepsis and acute respiratory failure in patients with cancer: how can we improve care and outcomes even further?

Lyons,

McEvoy,

Hayes-Lattin

2023

Current Opinion in Critical Care

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Purpose of review Care and outcomes of critically ill patients with cancer have improved over the past decade. This selective review will discuss recent updates in sepsis and acute respiratory failure among patients with cancer, with particular focus on important opportunities to improve outcomes further through attention to phenotyping, predictive analytics, and improved outcome measures. Recent findings The prevalence of cancer diagnoses in intensive care units (ICUs) is nontrivial and increasing. Sepsis and acute respiratory failure remain the most common critical illness syndromes affecting these patients, although other complications are also frequent. Recent research in oncologic sepsis has described outcome variation – including ICU, hospital, and 28-day mortality – across different types of cancer (e.g., solid vs. hematologic malignancies) and different sepsis definitions (e.g., Sepsis-3 vs. prior definitions). Research in acute respiratory failure in oncology patients has highlighted continued uncertainty in the value of diagnostic bronchoscopy for some patients and in the optimal respiratory support strategy. For both of these syndromes, specific challenges include multifactorial heterogeneity (e.g. in etiology and/or underlying cancer), delayed recognition of clinical deterioration, and complex outcomes measurement. Summary Improving outcomes in oncologic critical care requires attention to the heterogeneity of cancer diagnoses, timely recognition and management of critical illness, and defining appropriate ICU outcomes.

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Variability in triage practices for critically ill cancer patients: A randomized controlled trial

Cited by 7 publications

References 43 publications

Physicians’ Views and Agreement about Patient- and Context-Related Factors Influencing ICU Admission Decisions: A Prospective Study

Physicians’ Views and Agreement about Patient- and Context-Related Factors Influencing ICU Admission Decisions: A Prospective Study

Predictors of Delayed Recognition of Critical Illness in Emergency Department Patients and Its Effect on Morbidity and Mortality

Sepsis and acute respiratory failure in patients with cancer: how can we improve care and outcomes even further?

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