Triage: what can we do to improve our practice?

Excerpt

When necessary, the triage of adult intensive care patients is one of the most difficult challenges to the physician, carrying the risk of inadvertent patient harm and the danger of overuse, underuse or misuse of scarce specialized and costly ICU beds. From this perspective, the paper published by Sprung et al. in the official journal of the European Society of Intensive Care Medicine (ESICM) is very welcome [1]. While rationing appears to be increasing in most countries, the process of triage is often informal and practical aspects are implemented in divergent ways [2]. It could therefore be argued that general organizational and ethical principles are important to share in order to reduce heterogeneity and improve fairness within and between countries. While aspects of a generally accepted ethical framework may guide triage decision making, final clinical decisions are influenced by many additional operational factors. Several parameters may account for discrepancies between units: number of ICU beds [3], type of hospital, case-mix, culture and organization. The type of patient that is proposed for an ICU admission and the size, type and occupancy rate of the unit are important determinants of the final decision. Therefore these consensus opinions should be interpreted in context and with caution when applied to clinical decision making. For example, it is not clear whether the consensus is focused only on severe patients requiring several organ support (level of care III) or if it may encompass less severe patients including intermediate care patients (level of care I). …