Allocating critical care resources optimally and equitably involves many factors, starting with considering the benefits of admission to the intensive care unit (ICU) against the risks.
A multidisciplinary task force of the World Federation of Societies of Intensive and Critical Care Medicine has published general guidance on triage, in a report published in the Journal of Critical Care. The report is designed to inform regional and local initiatives on triage policy.
The Task Force emphasised that the discussion on resource allocation should not only be confined to the individual ICU:
“Ethics committees, government bodies, and society as a whole need to participate in a discussion about the principles involved in defining policies to allocate resources in each country. A worldwide deliberation on these issues will benefit critical care patients and professionals and ultimately communities.”
The Task Force considered 4 questions on triage.
Who will Benefit from Admission?
Patients from other wards who are not responding to therapy, patients at risk of complications needing immediate intervention and on occasion patients with end-state disease who need symptom control and patients who need specific organ support.
Ideally hospitals should have written ICU admission policies, shared with all stakeholders, including patients, say the Task Force. Triage scores should not be used routinely due to their limitations, but may be needed in extreme conditions, such as pandemics.
See Also: Who Benefits from Intensive Care?
Often the decision to admit is down to the intensivist’s judgement. The Task Force recommend consultation on admission with the multidisciplinary team.
What In-Hospital Factors Limit Admission?
The Task Force observe that flow into and out of the ICU need to be optimised, to avoid patients deteriorating in general wards, to ensure patients are admitted early to the ICU when needed, and discharge criteria need to be optimised.
Coordination with the emergency department is essential, say the Task Force. If there is not enough ICU capacity in the hospital, this can be addressed by expanding units, revising triage policies, reducing throughput delays, and creating step-down and/or HDUs for patients with lower risk that cannot be adequately cared for on ordinary wards, they suggest.
What Other Factors Should Influence Admission Decisions?
The Task Force notes that patient preference should be taken into account, although it is not a triage criterion.
“Triage decisions can give rise to conflicts between the ethical principles of distributive justice and obligations to individual patients..Although triage tools may support and improve the quality of critical care admission decisions, they probably cannot and should not supplant intensivists' experience and clinical judgment in decision making.”
If there are not enough ICU beds for the patients that need them, ICU staff should speak out as well as optimise resource allocation, say the Task Force.
Other recent Task Force reports from the World Federation of Societies of Intensive Care Medicine include end-of-life care and what an ICU specialist is.
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