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Triage of intensive care patients: identifying agreement and controversy

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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.

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References

  1. Society of Critical Care Medicine. Ethics Committee (1994) Consensus statement on the triage of critically ill patients. JAMA 271:1200–1203

    Article  Google Scholar 

  2. Metcalfe MA, Sloggett A, McPherson K (1997) Mortality among appropriately referred patients refused admission to intensive care units. Lancet 350:7–11

    Article  PubMed  CAS  Google Scholar 

  3. Sprung CL, Geber D, Eidelman LA, Baras M, Pizov R, Nimrod A, Oppenheim A, Epstein L, Cotev S (1999) Evaluation of triage decisions for intensive care admission. Crit Care Med 27:1073–1079

    Article  PubMed  CAS  Google Scholar 

  4. Joynt GM, Gomersall CD, Tan P, Lee A, Cheng CA, Wong EL (2001) Prospective evaluation of patients refused admission to an intensive care unit: triage, futility and outcome. Intensive Care Med 27:1459–1465

    Article  PubMed  CAS  Google Scholar 

  5. Simchen E, Sprung CL, Galai N, Zitser-Gurevich Y, Bar-Lavi Y, Gurman G, Klein M, Lev A, Levi L, Zveibil F, Mandel M, Mnatzaganian G (2004) Survival of critically ill patients hospitalized in and out of intensive care units under paucity of intensive care unit beds. Crit Care Med 32:1654–1661

    Article  PubMed  Google Scholar 

  6. Garrouste-Orgeas M, Montuclard L, Timsit JF, Reignier J, Desmettre T, Karoubi P, Moreau D, Montesino L, Duguet A, Boussat S, Ede C, Monseau Y, Paule T, Misset B, Carlet J, French ADMISSIONREA Study Group (2005) Predictors of intensive care unit refusal in French intensive care units: a multiple-center study. Crit Care Med 33:750–755

    Article  PubMed  Google Scholar 

  7. Hurst SA, Slowther AM, Forde R et al (2006) Prevalence and determinants of physician bedside rationing: data from Europe. J Gen Int Med 21:1138–1143

    Article  Google Scholar 

  8. Simchen E, Sprung CL, Galai N, Zitser-Gurevich Y, Bar-Lavi Y, Levi L, Zveibil F, Mandel M, Mnatzaganian G, Goldschmidt N, Ekka-Zohar A, Weiss-Salz I (2007) Survival of critically ill patients hospitalized in and out of intensive care. Crit Care Med 35:449–457

    Article  PubMed  Google Scholar 

  9. Hope T, McMillan J, Hill E (2012) Intensive care triage: priority should be independent of whether patients are already receiving intensive care. Bioethics 26:259–266

    Article  PubMed  Google Scholar 

  10. Reignier JRR, Tournoux-Facon C, Boulain T, Lesieur O et al (2012) Refusal of intensive care unit admission due to a full unit: impact on mortality. Am J Respir Crit Care Med 185:1081–1087

    Article  PubMed  Google Scholar 

  11. Akkaoui M, Abidi K, Louriz M et al (2012) Determinants and outcomes associated with decisions to deny or to delay intensive care unit admission in Morocco. Intensive Care Med 38:830–837

    Article  PubMed  Google Scholar 

  12. Mery E, Kahn JM (2013) Does space make waste? The influence of ICU bed capacity on admission decisions. Crit Care 17:315

    Article  PubMed  Google Scholar 

  13. Sinuff T, Kahnamoui K, Cook DJ, Luce JM, Levy MM, For the Values Ethics and Rationing in Critical Care (VERICC) Task Force (2004) Rationing critical care beds: a systematic review. Crit Care Med 32:1588–1597

    Article  PubMed  Google Scholar 

  14. Strech D, Synofzik M, Marckmann G (2008) How physicians allocate scarce resources at the bedside: a systematic review of qualitative studies. J Med Phil 33:80–99

    Article  Google Scholar 

  15. Azoulay E, Pochard F, Chevret S, Vinsonneau C, Garrouste M, Cohen Y, Thuong M, Paugam C, Apperre C, De Cagny B, Brun F, Bornstain C, Parrot A, Thamion F, Lacherade JC, Bouffard Y, Le Gall JR, Herve C, Grassin M, Zittoun R, Schlemmer B, Dhainaut JF, For the PROTOCETIC Group (2001) Compliance with triage to intensive care recommendations. Crit Care Med 29:2132–2136

    Article  PubMed  CAS  Google Scholar 

  16. Rhodes A, Ferdinande P, Flaatten H, Guidet B, Metnitz PG, Moreno RP (2012) The variability of critical care bed numbers in Europe. Intensive Care Med 38:1647–1653

    Article  PubMed  CAS  Google Scholar 

  17. Cooper AB, Sibbald R, Scales DC, Rozmovits L, Sinuff T (2013) Scarcity: the context of rationing in an Ontario ICU. Crit Care Med 41:1476–1482

    Article  PubMed  Google Scholar 

  18. American Thoracic Society Bioethics Task Force (1997) Fair allocation of intensive care unit resources. Am J Respir Crit Care Med 156:1282–1301

    Article  Google Scholar 

  19. Iapichino G, Corbella D, Minelli C, Mills G, Artigas A, Edbooke D, Pezzi A, Kesecioglu J, Patroniti N, Baras M, Sprung CL (2010) Reasons for refusal of admission to intensive care and impact on mortality. Intensive Care Med 36:1772–1779

    Article  PubMed  Google Scholar 

  20. Sprung CL, Baras M, Iapichino G, Kesecioglu J, Lippert A, Hargreaves C, Pezzi A, Pirrachio R, Edbrooke DL, Pesenti A, Bakker J, Gurman G, Cohen SL, Wiis J, Payen D, Artigas A (2012) The Eldicus prospective, observational study of triage decision making in European intensive care units: part I—European intensive care admission triage score (EICATS). Crit Care Med 40:125–131

    Article  PubMed  Google Scholar 

  21. Sprung CL, Artigas A, Kesecioglu J, Pezzi A, Wiis J, Pirrachio R, Baras M, Edbrooke DL, Pesenti A, Bakker J, Hargreaves C, Gurman G, Cohen SL, Lippert A, Payen D, Corbella D, Iapichino G (2012) The Eldicus prospective, observational study of triage decision making in European intensive care units. Part II: intensive care benefit for the elderly. Crit Care Med 40:132–138

    Article  PubMed  Google Scholar 

  22. Christian MD, Joynt GM, Colvn J, Hick JL, Danis M, Sprung CL (2010) Critical care triage. In: Sprung CL, Cohen R, Adini B (eds) Recommendations and standard operating procedures for intensive care unit and hospital preparations for an influenza epidemic or mass disaster. Summary report of the European Society of Intensive Care Medicine’s Task Force for intensive care unit triage during an influenza epidemic or mass disaster. Intensive Care Med 36:S55–S64

    Google Scholar 

  23. Satterthwaite PS, Atkinson CJ (2012) Using ‘reverse triage’ to create hospital surge capacity: Royal Darwin Hospital’s response to the Ashmore Reef disaster. Emerg Med J 29:160–162

    Article  PubMed  Google Scholar 

  24. Valentin A, Ferdinande P, ESICM Working Group on Quality Improvement (2011) Recommendations on basic requirements for intensive care units: structural and organizational aspects. Intensive Care Med 37:1575–1587

    Article  PubMed  Google Scholar 

  25. Knaus WA, Wagner DP, Lynn J (1991) Short-term mortality predictions for critically ill hospitalized adults: science and ethics. Science 254:389–394

    Article  PubMed  CAS  Google Scholar 

  26. Truog RD (1992) Triage in the ICU. Hast Cent Rep 22:13–17

    Article  CAS  Google Scholar 

  27. Danis M, Biddle AK, Goold SD (2004) Enrollees choose priorities for Medicare. Gerontologist 44:58–67

    Article  PubMed  Google Scholar 

  28. Baker R, Strosberg M (1992) Triage and equality: an historical reassessment of utilitarian analyses of triage. Kennedy Inst Ethics J 2:103–123

    Article  PubMed  CAS  Google Scholar 

  29. Persad G, Wertheimer A, Emanuel EJ (2009) Principles for allocation of scarce medical interventions. Lancet 373:423–431

    Article  PubMed  Google Scholar 

  30. Callahan D (1987) Setting limits. Medical goals in an aging society. Simon and Schuster, New York

  31. Daniels N (1983) Justice between age groups: am I my parents’ keeper? Milbank Mem Fund Q Health Soc 61:489–522

    Article  PubMed  CAS  Google Scholar 

  32. Levin PD, Sprung CL (2001) The process of intensive care triage. Intensive Care Med 27:1441–1445

    Article  PubMed  CAS  Google Scholar 

  33. Lecuyer L, Chevret S, Thiery G, Darmon M, Schlemmer B, Azoulay E (2007) The ICU trial: a new admission policy for cancer patients requiring mechanical ventilation. Crit Care Med 35:808–814

    Article  PubMed  Google Scholar 

Download references

Acknowledgments

Supported by the European Commission contract QLK6-CT-2002-00251, the European Society of Intensive Care Medicine and the European Critical Care Research Network, The Israel National Institute for Health Policy and Health Services Research grant number 1998/11/G and by Red GIRA G03/063. The EU Commission and other sponsors had no role in the design and conduct of the study, the collection, management, analysis, and interpretation of the data, or in the preparation, review, or approval of the manuscript. All authors participated in the design of the study, helped in the analysis of the data, and collaborated in drafting and revising the manuscript. As this is a study of triage and ethical issues, the authors’ have no financial or personal relationships or affiliations that could influence (or bias) their decisions, work, or manuscript.

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Authors and Affiliations

  1. General Intensive Care Unit, Department of Anesthesiology and Critical Care Medicine, Hadassah Hebrew University Medical Center, P.O. Box 12000, Jerusalem, 91120, Israel

    Charles L. Sprung

  2. Section on Ethics and Health Policy, National Institutes of Health, Bethesda, MD, USA

    Marion Danis

  3. San Paolo Hospital, Università degli Studi Milan, Milan, Italy

    Gaetano Iapichino

  4. Critical Care Center, Sabadell Hospital, CIBER Enfermedades Respiratorias, Parc Tauli University Institute, Autonomous University of Barcelona, Sabadell, Spain

    Antonio Artigas

  5. Department of Intensive Care Medicine, University Medical Center Utrecht, Utrecht, Netherlands

    Jozef Kesecioglu

  6. Unidade de Cuidados Intensivos Neurocríticos, Hospital de São José, Centro Hospitalar de Lisboa Central, E.P.E., Lisbon, Portugal

    Rui Moreno

  7. Herlev University Hospital, Copenhagen, Denmark

    Anne Lippert

  8. Division of Pulmonary and Critical Care Medicine, Harborview Medical Center, Seattle, WA, USA

    J. Randall Curtis

  9. Division of Surgery and Interventional Science, University College London, London, UK

    Paula Meale

  10. Department of Intensive Care Medicine, University College London, London, UK

    Simon L. Cohen

  11. Division of Pulmonary and Critical Care Medicine, Rhode Island Hospital, The Warren Alpert Medical School of Brown University, Providence, RI, USA

    Mitchell M. Levy

  12. Divisions of Medical Ethics, Anaesthesiology and Pediatrics, Children’s Hospital, Harvard Medical School, Boston, MA, USA

    Robert D. Truog

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  1. Charles L. Sprung
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  2. Marion Danis
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  3. Gaetano Iapichino
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  4. Antonio Artigas
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  5. Jozef Kesecioglu
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  6. Rui Moreno
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  7. Anne Lippert
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  8. J. Randall Curtis
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  9. Paula Meale
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  10. Simon L. Cohen
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  11. Mitchell M. Levy
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  12. Robert D. Truog
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Corresponding author

Correspondence to Charles L. Sprung.

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Sprung, C.L., Danis, M., Iapichino, G. et al. Triage of intensive care patients: identifying agreement and controversy. Intensive Care Med 39, 1916–1924 (2013). https://doi.org/10.1007/s00134-013-3033-6

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  • DOI: https://doi.org/10.1007/s00134-013-3033-6

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