1
|
Dahine J, Hébert PC, Ziegler D, Chenail N, Ferrari N, Hébert R. Practices in Triage and Transfer of Critically Ill Patients: A Qualitative Systematic Review of Selection Criteria. Crit Care Med 2020; 48:e1147-e1157. [PMID: 32858530 PMCID: PMC7493782 DOI: 10.1097/ccm.0000000000004624] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
OBJECTIVES To identify and appraise articles describing criteria used to prioritize or withhold a critical care admission. DATA SOURCES PubMed, Embase, Medline, EBM Reviews, and CINAHL Complete databases. Gray literature searches and a manual review of references were also performed. Preferred Reporting Items for Systematic reviews and Meta-Analyses guidelines were followed. STUDY SELECTION We sought all articles and abstracts of original research as well as local, provincial, or national policies on the topic of ICU resource allocation. We excluded studies whose population of interest was neonatal, pediatric, trauma, or noncritically ill. Screening of 6,633 citations was conducted. DATA EXTRACTION Triage and/or transport criteria were extracted, based on type of article, methodology, publication year, and country. An appraisal scale was developed to assess the quality of identified articles. We also developed a robustness score to further appraise the robustness of the evidence supporting each criterion. Finally, all criteria were extracted, evaluated, and grouped by theme. DATA SYNTHESIS One-hundred twenty-nine articles were included. These were mainly original research (34%), guidelines (26%), and reviews (21%). Among them, we identified 200 unique triage and transport criteria. Most articles highlighted an exclusion (71%) rather than a prioritization mechanism (17%). Very few articles pertained to transport of critically ill patients (4%). Criteria were classified in one of four emerging themes: patient, condition, physician, and context. The majority of criteria used were nonspecific. No study prospectively evaluated the implementation of its cited criteria. CONCLUSIONS This systematic review identified 200 criteria classified within four themes that may be included when devising triage programs including the coronavirus disease 2019 pandemic. We identified significant knowledge gaps where research would assist in improving existing triage criteria and guidelines, aiming to decrease arbitrary decisions and variability.
Collapse
Affiliation(s)
- Joseph Dahine
- Département de médecine spécialisée, Centre intégré de santé et services sociaux de Laval (CISSS de Laval), Hôpital Cité-de-la-Santé, Université de Montréal, Laval, QC, Canada
| | - Paul C. Hébert
- Département de médecine, Centre Hospitalier de l’Université de Montréal, Université de Montréal et Centre de Recherche, Montreal, QC, Canada
| | - Daniela Ziegler
- Bibliothèque, Centre hospitalier de l’Université de Montréal, Montreal, QC, Canada
| | | | - Nicolay Ferrari
- Centre de recherche du Centre hospitalier de l’Université de Montréal, Montreal, QC, Canada
| | - Réjean Hébert
- Department of Health Management, Evaluation and Policy, School of Public Health, Université de Montréal, Montreal, QC, Canada
| |
Collapse
|
2
|
U.K. Intensivists' Preferences for Patient Admission to ICU: Evidence From a Choice Experiment. Crit Care Med 2020; 47:1522-1530. [PMID: 31385883 PMCID: PMC6798748 DOI: 10.1097/ccm.0000000000003903] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Abstract
Supplemental Digital Content is available in the text. Deciding whether to admit a patient to the ICU requires considering several clinical and nonclinical factors. Studies have investigated factors associated with the decision but have not explored the relative importance of different factors, nor the interaction between factors on decision-making. We examined how ICU consultants prioritize specific factors when deciding whether to admit a patient to ICU.
Collapse
|
3
|
Rees S, Bassford C, Dale J, Fritz Z, Griffiths F, Parsons H, Perkins GD, Slowther AM. Implementing an intervention to improve decision making around referral and admission to intensive care: Results of feasibility testing in three NHS hospitals. J Eval Clin Pract 2020; 26:56-65. [PMID: 31099118 PMCID: PMC7003751 DOI: 10.1111/jep.13167] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/14/2019] [Revised: 04/16/2019] [Accepted: 04/18/2019] [Indexed: 10/29/2022]
Abstract
RATIONALE, AIMS, AND OBJECTIVES Decisions about whether to refer or admit a patient to an intensive care unit (ICU) are clinically, organizationally, and ethically challenging. Many explicit and implicit factors influence these decisions, and there is substantial variability in how they are made, leading to concerns about access to appropriate treatment for critically ill patients. There is currently no guidance to support doctors making these decisions. We developed an intervention with the aim of supporting doctors to make more transparent, consistent, patient-centred, and ethically justified decisions. This paper reports on the implementation of the intervention at three NHS hospitals in England and evaluates its feasibility in terms of usage, acceptability, and perceived impact on decision making. METHODS A mixed method study including quantitative assessment of usage and qualitative interviews. RESULTS There was moderate uptake of the framework (28.2% of referrals to ICU across all sites during the 3-month study period). Organizational structure and culture affected implementation. Concerns about increased workload in the context of limited resources were obstacles to its use. Doctors who used it reported a positive impact on decision making, with better articulation and communication of reasons for decisions, and greater attention to patient wishes. The intervention made explicit the uncertainty inherent in these decisions, and this was sometimes challenging. The patient and family information leaflets were not used. CONCLUSIONS While it is feasible to implement an intervention to improve decision making around referral and admission to ICU, embedding the intervention into existing organizational culture and practice would likely increase adoption. The doctor-facing elements of the intervention were generally acceptable and were perceived as making ICU decision making more transparent and patient-centred. While there remained difficulties in articulating the clinical reasoning behind some decisions, the intervention offers an important step towards establishing a more clinically and ethically sound approach to ICU admission.
Collapse
Affiliation(s)
- Sophie Rees
- Warwick Medical School, University of Warwick, Coventry, UK
| | - Christopher Bassford
- Warwick Medical School, University of Warwick, Coventry, UK.,University Hospitals Coventry and Warwickshire NHS Trust, Coventry, UK
| | - Jeremy Dale
- Warwick Medical School, University of Warwick, Coventry, UK
| | - Zoe Fritz
- Cambridge University Hospital NHS Trust, Cambridge, UK
| | - Frances Griffiths
- Warwick Medical School, University of Warwick, Coventry, UK.,University of the Witwatersrand, Johannesburg, South Africa
| | - Helen Parsons
- Warwick Medical School, University of Warwick, Coventry, UK
| | - Gavin D Perkins
- Warwick Medical School, University of Warwick, Coventry, UK.,Heartlands Hospital, University Hospitals Birmingham, Birmingham, UK
| | - Anne Marie Slowther
- Warwick Medical School, University of Warwick, Coventry, UK.,University Hospitals Coventry and Warwickshire NHS Trust, Coventry, UK
| |
Collapse
|
4
|
Bassford C, Griffiths F, Svantesson M, Ryan M, Krucien N, Dale J, Rees S, Rees K, Ignatowicz A, Parsons H, Flowers N, Fritz Z, Perkins G, Quinton S, Symons S, White C, Huang H, Turner J, Brooke M, McCreedy A, Blake C, Slowther A. Developing an intervention around referral and admissions to intensive care: a mixed-methods study. HEALTH SERVICES AND DELIVERY RESEARCH 2019. [DOI: 10.3310/hsdr07390] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022] Open
Abstract
BackgroundIntensive care treatment can be life-saving, but it is invasive and distressing for patients receiving it and it is not always successful. Deciding whether or not a patient will benefit from intensive care is a difficult clinical and ethical challenge.ObjectivesTo explore the decision-making process for referral and admission to the intensive care unit and to develop and test an intervention to improve it.MethodsA mixed-methods study comprising (1) two systematic reviews investigating the factors associated with decisions to admit patients to the intensive care unit and the experiences of clinicians, patients and families; (2) observation of decisions and interviews with intensive care unit doctors, referring doctors, and patients and families in six NHS trusts in the Midlands, UK; (3) a choice experiment survey distributed to UK intensive care unit consultants and critical care outreach nurses, eliciting their preferences for factors used in decision-making for intensive care unit admission; (4) development of a decision-support intervention informed by the previous work streams, including an ethical framework for decision-making and supporting referral and decision-support forms and patient and family information leaflets. Implementation feasibility was tested in three NHS trusts; (5) development and testing of a tool to evaluate the ethical quality of decision-making related to intensive care unit admission, based on the assessment of patient records. The tool was tested for inter-rater and intersite reliability in 120 patient records.ResultsInfluences on decision-making identified in the systematic review and ethnographic study included age, presence of chronic illness, functional status, presence of a do not attempt cardiopulmonary resuscitation order, referring specialty, referrer seniority and intensive care unit bed availability. Intensive care unit doctors used a gestalt assessment of the patient when making decisions. The choice experiment showed that age was the most important factor in consultants’ and critical care outreach nurses’ preferences for admission. The ethnographic study illuminated the complexity of the decision-making process, and the importance of interprofessional relationships and good communication between teams and with patients and families. Doctors found it difficult to articulate and balance the benefits and burdens of intensive care unit treatment for a patient. There was low uptake of the decision-support intervention, although doctors who used it noted that it improved articulation of reasons for decisions and communication with patients.LimitationsLimitations existed in each of the component studies; for example, we had difficulty recruiting patients and families in our qualitative work. However, the project benefited from a mixed-method approach that mitigated the potential limitations of the component studies.ConclusionsDecision-making surrounding referral and admission to the intensive care unit is complex. This study has provided evidence and resources to help clinicians and organisations aiming to improve the decision-making for and, ultimately, the care of critically ill patients.Future workFurther research is needed into decision-making practices, particularly in how best to engage with patients and families during the decision process. The development and evaluation of training for clinicians involved in these decisions should be a priority for future work.Study registrationThe systematic reviews of this study are registered as PROSPERO CRD42016039054, CRD42015019711 and CRD42015019714.FundingThe National Institute for Health Research Health Services and Delivery Research programme. The University of Aberdeen and the Chief Scientist Office of the Scottish Government Health and Social Care Directorates fund the Health Economics Research Unit.
Collapse
Affiliation(s)
- Chris Bassford
- Warwick Medical School, University of Warwick, Coventry, UK
- Department of Anaesthesia, Critical Care and Pain, University Hospitals Coventry and Warwickshire NHS Trust, Coventry, UK
| | | | - Mia Svantesson
- University Health Care Research Center, Faculty of Medicine and Health, Örebro University, Örebro, Sweden
| | - Mandy Ryan
- Health Economics Research Unit, Institute of Applied Health Sciences, University of Aberdeen, Aberdeen, UK
| | - Nicolas Krucien
- Health Economics Research Unit, Institute of Applied Health Sciences, University of Aberdeen, Aberdeen, UK
| | - Jeremy Dale
- Warwick Medical School, University of Warwick, Coventry, UK
| | - Sophie Rees
- Warwick Medical School, University of Warwick, Coventry, UK
| | - Karen Rees
- Warwick Medical School, University of Warwick, Coventry, UK
| | - Agnieszka Ignatowicz
- Warwick Medical School, University of Warwick, Coventry, UK
- Institute of Applied Health Research, College of Medical and Dental Sciences, University of Birmingham, Birmingham, UK
| | - Helen Parsons
- Warwick Medical School, University of Warwick, Coventry, UK
| | - Nadine Flowers
- Warwick Medical School, University of Warwick, Coventry, UK
| | - Zoe Fritz
- Warwick Medical School, University of Warwick, Coventry, UK
- Department of Acute Medicine, Cambridge University Hospitals NHS Trust, Cambridge, UK
- The Healthcare Improvement Studies (THIS) Institute, University of Cambridge, Cambridge, UK
| | - Gavin Perkins
- Warwick Medical School, University of Warwick, Coventry, UK
- Heartlands Hospital, University Hospitals Birmingham, Birmingham, UK
| | - Sarah Quinton
- Warwick Medical School, University of Warwick, Coventry, UK
- Health Economics Research Unit, Institute of Applied Health Sciences, University of Aberdeen, Aberdeen, UK
| | | | | | - Huayi Huang
- Warwick Medical School, University of Warwick, Coventry, UK
| | - Jake Turner
- Warwick Medical School, University of Warwick, Coventry, UK
| | - Mike Brooke
- Warwick Medical School, University of Warwick, Coventry, UK
| | - Aimee McCreedy
- Warwick Medical School, University of Warwick, Coventry, UK
| | - Caroline Blake
- Warwick Medical School, University of Warwick, Coventry, UK
| | - Anne Slowther
- Warwick Medical School, University of Warwick, Coventry, UK
| |
Collapse
|
5
|
James FR, Power N, Laha S. Decision-making in intensive care medicine - A review. J Intensive Care Soc 2017; 19:247-258. [PMID: 30159017 DOI: 10.1177/1751143717746566] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Decision-making by intensivists around accepting patients to intensive care units is a complex area, with often high-stakes, difficult, emotive decisions being made with limited patient information, high uncertainty about outcomes and extreme pressure to make these decisions quickly. This is exacerbated by a lack of clear guidelines to help guide this difficult decision-making process, with the onus largely relying on clinical experience and judgement. In addition to uncertainty compounding decision-making at the individual clinical level, it is further complicated at the multi-speciality level for the senior doctors and surgeons referring to intensive care units. This is a systematic review of the existing literature about this decision-making process and the factors that help guide these decisions on both sides of the intensive care unit admission dilemma. We found many studies exist assessing the patient factors correlated with intensive care unit admission decisions. Analysing these together suggests that factors consistently found to be correlated with a decision to admit or refuse a patient from intensive care unit are bed availability, severity of illness, initial ward or team referred from, patient choice, do not resuscitate status, age and functional baseline. Less research has been done on the decision-making process itself and the factors that are important to the accepting intensivists; however, similar themes are seen. Even less research exists on referral decision and demonstrates that in addition to the factors correlated with intensive care unit admission decisions, other wider variables are considered by the referring non-intensivists. No studies are available that investigate the decision-making process in referring non-intensivists or the mismatch of processes and pressure between the two sides of the intensive care unit referral dilemma.
Collapse
Affiliation(s)
- Fiona R James
- Critical Care Unit, Lancashire Teaching Hospitals NHS Foundation Trust, Preston, UK
| | - Nicola Power
- Department of Psychology, Lancaster University, UK
| | - Shondipon Laha
- Critical Care Unit, Lancashire Teaching Hospitals NHS Foundation Trust, Preston, UK
| |
Collapse
|
6
|
Manerikar S, Hariharan S. Do Serially Recorded Prognostic Scores Predict Outcome Better Than One-Time Recorded Score on Admission? A Prospective Study in Adult Intensive Care Patients. J Intensive Care Med 2016; 32:480-486. [PMID: 26768423 DOI: 10.1177/0885066615625937] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
OBJECTIVES The prognosticating ability of one-time recorded Acute Physiology and Chronic Health Evaluation (APACHE) IV score was compared with serially recorded Mortality Prediction Model (MPM) II scores. DESIGN AND METHODS A prospective observational study was conducted for a period of 6 months. Acute Physiology and Chronic Health Evaluation IV score was recorded during the first day on intensive care unit (ICU) admission. Mortality Prediction Model II was recorded on admission, 24, 48, and 72 hours. Predicted mortality was compared with observed mortality. The systems were calibrated and tested for discriminant functions. RESULTS One hundred and fifty patients were studied. The observed mortality was 21.3%. The mean predicted hospital mortality by APACHE IV was 20.6%. The mean predicted hospital mortality rate by serial MPM II measurements was 27.7%, 24.3%, 25.5%, and 25.8%. The area under the receiver-operating characteristic curve was 0.87 for APACHE IV and 0.82, 0.84, 0.85, and 0.89 for MPM II series. Both systems calibrated well with similar degree of goodness of fit. CONCLUSION Acute Physiology and Chronic Health Evaluation IV on admission predicted hospital mortality better than serially recorded MPM, which overestimated mortality. Also, APACHE IV had a slightly better discrimination compared to MPM II on admission. One-time recording of APACHE IV on admission may be sufficient for prognostication of ICU patients rather than serial MPM scores.
Collapse
Affiliation(s)
- Sangeeta Manerikar
- 1 Anaesthesia and Intensive Care Unit, Faculty of Medical Sciences, The University of the West Indies, St Augustine, West Indies
| | - Seetharaman Hariharan
- 1 Anaesthesia and Intensive Care Unit, Faculty of Medical Sciences, The University of the West Indies, St Augustine, West Indies
| |
Collapse
|
7
|
Semei-Spencer TT, Kinthala S, Fakoory M, Gaskin P, Hariharan S, Areti YK. Outcomes and Health-related Quality of Life following Intensive Care Unit Stay in Barbados. W INDIAN MED J 2014; 63:447-53. [PMID: 25781281 PMCID: PMC4655689 DOI: 10.7727/wimj.2013.139] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2013] [Accepted: 10/25/2013] [Indexed: 11/18/2022]
Abstract
OBJECTIVES To evaluate the hospital outcome and health-related quality of life (HRQOL) in adult patients admitted to intensive care units (ICUs) in Barbados. METHODS A prospective observational study was done in the medical and surgical intensive care units of the Queen Elizabeth Hospital, Barbados, to evaluate the outcomes and HRQOL in adult patients. The acute physiology and chronic health evaluation (APACHE) IV score was applied on admission to one hundred and fifty patients admitted to the ICUs. The HRQOL was evaluated by using Short Form 36 (SF-36) in 63 survivors, three months after ICU discharge. RESULTS There was no significant difference between medical and surgical ICUs with respect to age, gender, APACHE IV scores, 90-day mortality, and length of stay. The mean (± SD) APACHE IV score was 42.6 (± 23.7). The observed mortality was 32.7% and the standardized mortality ratio (SMR) was 1.85. The APACHE IV scores were significantly higher in non-survivors compared to survivors (p < 0.001). Patients with APACHE IV of > 45, and who were ventilated in the first 24 hours had the highest mortality (66%). The mean ICU length of stay was 7.2 days. CONCLUSION In this study, the SF-36 scores in all eight dimensions indicated that the HRQOL in the majority of the survivors was average or above average. There was a significant negative correlation between APACHE IV score and the SF-36 score.
Collapse
Affiliation(s)
- T T Semei-Spencer
- Department of Anaesthesia, Queen Elizabeth Hospital, Martindales Road, St Michael, Barbados
| | - S Kinthala
- Department of Anaesthesia, Queen Elizabeth Hospital, Martindales Road, St Michael, Barbados.
| | - M Fakoory
- Department of Anaesthesia, Queen Elizabeth Hospital, Martindales Road, St Michael, Barbados
| | - P Gaskin
- Essential National Health Research, Faculty of Medical Sciences, The University of the West Indies, Cave Hill, Barbados
| | - S Hariharan
- Anaesthesia and Intensive Care Unit, Department of Clinical Surgical Sciences, The University of the West Indies, St Augustine, Trinidad and Tobago
| | - Y K Areti
- Department of Anaesthesia and Intensive Care, Faculty of Medical Sciences, the University of the West Indies, Cave Hill, Barbados
| |
Collapse
|
8
|
Orsini J, Butala A, Ahmad N, Llosa A, Prajapati R, Fishkin E. Factors influencing triage decisions in patients referred for ICU admission. J Clin Med Res 2013; 5:343-9. [PMID: 23976906 PMCID: PMC3748658 DOI: 10.4021/jocmr1501w] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/09/2013] [Indexed: 01/09/2023] Open
Abstract
Background Few 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. Methods A 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. Results Seventy-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%. Conclusion Refusal 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.
Collapse
Affiliation(s)
- Jose Orsini
- Department of Medicine, New York University School of Medicine at Woodhull Medical and Mental Health Center, 760 Broadway, Brooklyn, NY 11206, USA
| | | | | | | | | | | |
Collapse
|