Charles L. Sprung
Director General Intensive Care Unit
Department of Anaesthesiology and Critical Care Medicine
Hadassah University, Hospital, Jerusalem, Israel
Professor of Intensive Care Medicine, Royal Hallamshire Hospital, Sheffield, UK
On Behalf of the ELDICUS investigators
The ELDICUS project is funded as part of the European RTD project ELDICUS – “Triage decision making for the Elderly in European Intensive Care Units” funded by the European Commission (Contract No. QLK2-CT-2002-00251) and in part by the European Society of Intensive Care Medicine.
ELDICUS investigators move another step towards identifying the elements for an objective triage decision making tool in a consensus meeting of 34 experts. ELDICUS is the project acronym for “Triage decision making for the ELDerly in European Intensive Care UnitS.
On 29th and 30th January 2006, 34 experts came together in Lisbon for a consensus meeting following preliminary research results of the ELDICUS project. This project aims to make triage decisions for the elderly in Europe more transparent, fair and cost-effective, and to deliver recommendations for public policy towards harmonising European standards. Literature research, data on more than 8000 triages across Europe (the largest trial of its kind) and the expertise of the investigators have contributed to this second stage of a consensus on 60 statements, designed to promote an objective triage decision making process. In addition to directors and professors of intensive care, the consensus group comprised Jane Barratt, Secretary General, and Yitzhcak Brick, President, of the International Federation for Aging, Avi Israeli, Director General of the Israeli Ministry of Health, and specialists from external healthcare consultancies, anaesthesiology, gerontology, statistics, economics and biophilosophy.
The ELDICUS project has comprised a number of challenging aims, including the design of a standardized triage score for ICU, the comparison of ICU costs across France, Spain, Italy, Denmark, the UK, the Netherlands and Israel, and social linkage analysis to help identify effective triage decision making solutions. Patient data before and after triage were collected, including demographic and physiologic data, and mortalities. Participating ICUs completed activity and cost forms based on the cost block methodology previously used in the UK (Edbrooke et al. 2004). Additionally, a social linkage analysis was completed by Professor of Applied Ethics, Guido Van Steendam, from K.U. Leuven. Based on the results of the study, and in part on earlier guidelines published by the Society of Critical Care Medicine (Society of Critical Care Medicine Ethics Committee 1994), 60 statements and guidelines for decision making in triage were drawn up and circulated in December 2005 for consideration by all the investigators and experts attending the consensus meeting in January 2006.
On the first day of the consensus meeting, the preliminary results of the ELDICUS project were presented. In addition, investigators and experts discussed results from the first evaluation stage for each of the 60 statements in depth, including recommendations for amendment, rejection or deletion of statements, and voted on each point. With consensus defined as agreement of over 80%, 42 of the 60 statements were accepted or amended as appropriate and agreed on during this second stage. All statements were reconsidered in a third stage on the second day of the meeting, with emphasis on discussing those without consensus. A further eight statements were agreed on and detailed comments on the remaining statements recorded to guide a subgroup of experts in a final round of consideration and amendment.
In the ELDICUS multi-centred trial, 50% of the triaged patients were over 65 years, with significant variation in refusal rates for the elderly between the different countries. Further in depth qualitative analysis was proposed at the consensus meeting to research what elements of the decision making process may lead to lower refusal rates of the elderly. Particularly focusing on the role of age in triage decision making, statement 31, which acquired 100% consensus in the third round, was concluded as “Age should never be the sole determining factor in triage decisions.” Social linkage analysis, however, identifies that one selection criterion can be used to hide another more controversial criterion. To further protect the elderly so that no decisions based on age can be hidden, and those who can benefit will benefit, the group agreed unanimously on a further statement related to physiological status and age: “Physiological status is more important than chronological age in triage decisions”.
Perhaps the most significant statement agreed on in this third round of consideration, was “An objective triage score should be used by physicians to help make triage decisions for individual patients”. Social linkage analysis suggests that selection criteria cannot be truly objective, because many criteria such as “quality” and “benefit” require subjective interpretation. The group debated, however, that objectivity and subjectivity are not a dichotomy, but a continuum, so that aiming for the objective end of the continuum remains a realistic goal. Additional solutions to not achieving the ideal of an entirely objective tool are recognition of the fact, and keeping the door open for continuous improvement.
Final consensus on all the statements is yet to be concluded following further statistical analysis and interpretation of the data collected in the ELDICUS study, further consideration of all the statements by the subcommittee, and final voting by all the experts and investigators.
ELDICUS is an EU funded project and closes at the end of April 2006, although analyses, meetings and publications are expected to continue long after.