ICU Triage: Service Beyond the Disposition

One of the most memorable nights of my medicine internship came 10 months in, when the second- and third-year residents were out of the hospital celebrating the end of the year. With the seniors away, we interns were left to run the show. Gulp!

I got the plum assignment of being the “ICU triage” resident. In this role—normally reserved for a PGY3—I evaluated patients throughout the 800-bed hospital for potential ICU admission. It was scary, challenging, and fun. I can still recall the exhilaration of racing floor to floor to see the sickest patients in the hospital and help care for them.

As memorable as the shift was, I have since wondered how I performed in the triage role that night, and whether I would make different decisions if I saw the same patients today. I’m now a third-year pulmonary and critical care fellow, have seen thousands more patients, and have returned to the triage role numerous times. Surely, with this experience I must be better equipped to determine who would benefit from admission to an ICU, right?

The answer may not be so simple. A pair of articles published this fall suggest we really do not know which patients benefit from intensive care.

In an October issue of Annals of Internal Medicine, researchers examined temporal and geographic variability in ICU admission for older adults with fee-for-service Medicare (1). Using national data from 2006 to 2015, they examined 88 million claims to determine ICU admission rates and how they changed over time and looked for a relationship between ICU capacity (the number of beds) and ICU admissions.

The investigators identified 15 million ICU admissions over the time frame (16.7% of all hospitalizations). Nationally, ICU admissions decreased from 6117 per 100,000 person-years in 2006 to 4247 per 100,000 person-years in 2015, whereas the number of ICU beds increased by 11%. On the state level, there was tremendous variability—with as much as a 3-fold difference in ICU admission rates, and changes in ICU capacity ranging from a loss of 38% of beds to a 54% increase. Differences in ICU capacity explained some (but not all) of the observed state-to-state variability in ICU utilization.

What does this all mean? Nationally, we have more ICU beds than ever before, but we are using them at a lower rate and we are using them unevenly. Bed availability seems to influence the decision to admit a patient to the ICU, but other factors also contribute.

It turns out that we are one of these factors.

In a recent Critical Care Medicine study (2), a team of investigators presented 8 hypothetical patients to over 1000 intensivists and asked them who would benefit from ICU admission. The degree of agreement between physicians was exceedingly poor (intra-class correlation coefficient of 0.06, with scores <0.40 representing “poor” agreement). For example, when faced with an 80-year-old tachypneic woman with pneumonia who needed 6 LPM of supplemental oxygen, “18% of physicians felt the patient would definitely benefit from ICU care, whereas 17% of physicians with the same case felt the patient would definitely benefit from general ward care.” The remainder of physicians were somewhere in the middle.

So, to recap—states have varying numbers of ICU beds, use them at different rates, and doctors disagree about which patients are good candidates for intensive care. What, then, does this mean for my opening question? If there is no consensus about who benefits from ICU admission, how am I to assess the quality of triage decisions I made 5 years ago?

Maybe asking about disposition decisions isn’t the right question. There is more to triage than getting the "right" disposition, and on these measures, I have certainly become more skilled.

I now understand the service I am providing to colleagues as an experienced internist—assisting clinicians from other disciplines who are out of their comfort zone. I’ve dispensed with the pride I used to feel for "denying" an ICU admission when a patient “wasn’t sick enough.” In contrast, I now understand that acuity of illness is only one potential indication for ICU admission, and I am happy to bring patients to the ICU for complex nursing care. I also strive to build consensus with all members of the interprofessional care team, and I regularly ask nurses, respiratory therapists, and others where they think a patient would be best cared for.
   
This isn’t to say that disposition decisions do not matter or discount the value of further training. Undoubtedly, as a critical care fellow, I now bring more knowledge and perspective to every disposition decision I make, and for this reason, I do believe I make better decisions than I did before. That we lack the objective means to assess this is problematic, and is an area for further research.

So, what advice would I give to an intern or a resident preparing to take on the triage role for the first time? I’d emphasize that triage is about more than managing acute illness. It’s a service built on sharing knowledge and guiding an interprofessional team. Fortunately, these are fundamental skills of the internist.

References

1. Weissman GE, Kerlin MP, Yuan Y, Gabler NB, Groeneveld PW, Werner RM, et al. Population trends in intensive care unit admissions in the United States among Medicare beneficiaries, 2006-2015. Ann Intern Med. 2018. [PMID: 30326008] doi:10.7326/M18-1425
2. Valley TS, Admon AJ, Zahuranec DB, Garland A, Fagerlin A, Iwashyna TJ. Estimating ICU benefit: a randomized study of physicians. Crit Care Med. 2019;47:62-68. [PMID: 30303839] doi:10.1097/CCM.0000000000003473