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01.12.2016 | Research | Ausgabe 1/2016 Open Access

Critical Care 1/2016

Development of an algorithm to aid triage decisions for intensive care unit admission: a clinical vignette and retrospective cohort study

Zeitschrift:
Critical Care > Ausgabe 1/2016
Autoren:
Joao Gabriel Rosa Ramos, Beatriz Perondi, Roger Daglius Dias, Leandro Costa Miranda, Claudio Cohen, Carlos Roberto Ribeiro Carvalho, Irineu Tadeu Velasco, Daniel Neves Forte
Wichtige Hinweise

Electronic supplementary material

The online version of this article (doi:10.​1186/​s13054-016-1262-0) contains supplementary material, which is available to authorized users.

Competing interests

The authors declare that they have no competing interests.

Authors’ contributions

JGRR, BP, and DNF contributed to the designing, acquisition, analysis and interpretation of data, drafting and revising the manuscript. RDD, LCM, CC, CRRC, and ITV contributed to the conception of the study and critical revision of the manuscript. All authors read and approved the final manuscript.

Abstract

Background

Intensive care unit (ICU) admission triage is performed routinely and is often based solely on clinical judgment, which could mask biases. A computerized algorithm to aid ICU triage decisions was developed to classify patients into the Society of Critical Care Medicine’s prioritization system. In this study, we sought to evaluate the reliability and validity of this algorithm.

Methods

Nine senior physicians evaluated forty clinical vignettes based on real patients. The reference standard was defined as the priorities ascribed by two investigators with full access to patients’ records. Agreement of algorithm-based priorities with the reference standard and with intuitive priorities provided by the physicians were evaluated. Correlations between algorithm prioritization and physicians’ judgment of the appropriateness of ICU admissions in scarcity and nonscarcity settings were also evaluated. Validity was further assessed by retrospectively applying this algorithm to 603 patients with requests for ICU admission for association with clinical outcomes.

Results

Agreement between algorithm-based priorities and the reference standard was substantial, with a median κ of 0.72 (interquartile range [IQR] 0.52–0.77). Algorithm-based priorities demonstrated higher interrater reliability (overall κ 0.61, 95 % confidence interval [CI] 0.57–0.65; median percentage agreement 0.64, IQR 0.59–0.70) than physicians’ intuitive prioritization (overall κ 0.51, 95 % CI 0.47–0.55; median percentage agreement 0.49, IQR 0.44–0.56) (p = 0.001). Algorithm-based priorities were also associated with physicians’ judgment of appropriateness of ICU admission (priorities 1, 2, 3, and 4 vignettes would be admitted to the last ICU bed in 83.7 %, 61.2 %, 45.2 %, and 16.8 % of the scenarios, respectively; p < 0.001) and with actual ICU admission, palliative care consultation, and hospital mortality in the retrospective cohort.

Conclusions

This ICU admission triage algorithm demonstrated good reliability and validity. However, more studies are needed to evaluate a difference in benefit of ICU admission justifying the admission of one priority stratum over the others.
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