ICU Admission, Discharge, and Triage Guidelines

We suggest that individual institutions and their ICU leaders develop policies to meet their specific population needs (e.g., trauma, burns, and neurological), taking into consideration their institutional limitations such as ICU size and therapeutic capabilities.

To optimize resource use while improving outcomes, we suggest guiding ICU admissions on the basis of a combination of:

We suggest using the following tools for bed allocation during the admission and triage processes:

We suggest patients needing life-sustaining interventions who have a higher probability of recovery and would accept cardiopulmonary resuscitation receive a higher priority for ICU admission than those with a significantly lower probability of recovery who choose not to receive cardiopulmonary resuscitation.

We suggest that patients with invasive mechanical ventilation or complex life-threatening conditions, including those with sepsis, be treated in an ICU. Patients should not be weaned from mechanical ventilation on the general ward unless the ward is a high-dependency/intermediate unit.

We suggest that critically ill patients in the emergency department or on the general ward be transferred to a higher level of care, such as the ICU, in an expeditious manner.

We suggest avoiding admitting to a specialized ICU patients with a primary diagnosis not associated with that specialty (i.e., boarding).

We suggest the admission of neurocritically ill patients to a neuro-ICU, especially those with a diagnosis of intracerebral hemorrhage or head injury.

We recommend a high-intensity ICU model, characterized by the intensivist being responsible for dayto- day management of the patient, either in a “closed ICU” setting (in which the intensivist serves as the primary physician) or through a hospital protocol for mandatory intensivist consultation.

We do not recommend a 24-hr/7-d intensivist model if the ICU has a high-intensity staffing model (vide supra) during the day or night.

We suggest optimizing ICU nursing resources and nursing ratios, taking into consideration available nursing resources (e.g., levels of education, support personnel, specific workloads), patients’ needs, and patients’ medical complexity.

Because of current constraints on the availability and cost of 24-hr intensivist coverage, further studies are needed to address the efficacy of coverage with critical care–trained advance practice providers, including nurse practitioners and physician assistants, and critical care telemedicine.

We suggest that patients receive ICU treatment if their prognosis for recovery and quality of life is acceptable regardless of their length of ICU stay. However, factors such as age, comorbidities, prognosis, underlying diagnosis, and treatment modalities that can influence survival should be taken into account.

We suggest that every ICU institute methods for prioritizing and triaging patients, with policies and guidelines that are disclosed in advance.

We suggest that triage decisions are made explicitly and without bias. Ethnic origin, race, sex, social status, sexual preference, or financial status should never be considered in triage decisions.

We suggest that, under ideal conditions, patients be admitted or discharged strictly on their potential to benefit from ICU care.

We suggest that some overtriage is more acceptable and preferable to undertriage.

We suggest minimizing the transfer time of critically ill patients from the emergency department to the ICU (<6 hr in nontrauma patients).

We suggest that, considering the frequent lack of rapid ICU bed availability, emergency medicine practitioners be prepared to deliver critical care in the emergency department.

In addition to optimization of the triage process from the emergency department to the ICU, we suggest close monitoring and timely intervention for those who are triaged to the ward. These interventions might reduce delayed transfers to the ICU of undertriaged patients and prevent acute deterioration of those still requiring stabilization after hospital admission.

We suggest that patients with risk factors for postoperative instability or decompensation be closely monitored and managed in a higher level of care unit than the ward in the immediate postoperative period.

There are insufficient data to make a recommendation for or against ICU-to-ICU interhospital transfer.

We suggest that all ICUs have designated additional equivalent beds, equipment, and staff necessary to support the critically ill during a mass casualty incident emergency response.

We suggest that a designated person or service, with control over resources and active involvement, be responsible for making ICU triage decisions during normal or emergency conditions.

We suggest basing the decision to admit an elderly (>80 yr) patient to an ICU on the patient’s comorbidities, severity of illness, prehospital functional status, and patient preferences with regard to life-sustaining treatment, not on their chronological age.

We suggest that ICU access of cancer patients be decided on the basis established for all critical care patients, with careful consideration of their long-term prognosis.

We suggest that ICU care of all critically ill patients, in particular, cancer patients with advanced disease, be reassessed and discussed with the patient, next of kin, legal representative, or power of attorney at regular intervals.

We suggest not using scoring systems alone to determine level of care or removal from higher levels of care because these are not accurate in predicting individual mortality.

We suggest that all hospitals and regional areas develop a coordinated triage plan for epidemics. The hospital plans should include both triage and dissemination of patients throughout the hospital.

We suggest that during epidemics, nontraditional settings be considered and utilized for the care of critically ill patients.

We suggest not using routine laboratory studies alone in determining the nature of illness during an epidemic.

We suggest that activation of the hospital disaster plan and a coordinated response of the entire healthcare team (e.g., physicians, nursing staff, environmental staff, administrators) follow the announcement of a mass casualty incident. The team should ensure that their institution and critical areas (emergency department, operating room, and ICU) are ready for the rapid and efficient transition from normal to emergency operations and increase their capacity to accommodate a larger volume of critically ill patients.

We suggest that the disaster response teams identify all patients in need of ICU care and those already hospitalized who could be discharged, and then triage and transfer the incoming patients to the most appropriate setting as soon as possible.

We suggest that in areas at risk, ICUs be prepared to deal with the victims of not only external disasters but also internal disasters, including collapse of surrounding services in large-scale disasters such as an earthquake, tsunami, or major tornado. Every ICU should have general disaster and evacuation plans such as those required by the Joint Commission Standards in the United States.

We suggest that every ICU stipulate specific discharge criteria in its ADT policy.

We suggest that it is appropriate to discharge a patient from the ICU to a lower acuity area when a patient’s physiologic status has stabilized and there no longer is a need for ICU monitoring and treatment.

We suggest that the discharge parameters be based on ICU admission criteria, the admitting criteria for the next lower level of care, institutional availability of these resources, patient prognosis, physiologic stability, and ongoing active interventions.

We suggest that, to improve resource utilization, discharge from the ICU is appropriate despite a deteriorated patient’s physiological status if active interventions are no longer planned.

We suggest refraining from transferring patients to lower acuity care areas based solely on severity-of-illness scores. General and specific severity-of-illness scoring systems can identify patient populations at higher risk of clinical deterioration after ICU discharge. However, their value for assessing the readiness for transfer of individual patients to lower acuity care has not been evaluated.

We suggest discharging patients at high risk for mortality and readmission (high severity of illness, multiple comorbidities, physiologic instability, ongoing organ support) to a step-down unit or longterm acute care hospital as opposed to the regular ward.

We suggest that a standardized process for discharge from the ICU be followed; both oral and written formats for the report may reduce readmission rate.

We suggest that rapid response systems be utilized for early review of acutely ill non-ICU patients to identify patients who need or would benefit from ICU admission and treatment and to prevent unnecessary ICU admissions.

We suggest that ICU consult teams be considered for use to facilitate transition from the ICU, assist ward staff in the management of deteriorating patients, facilitate transfer to ICU, and reduce rates of readmission to critical care.

We suggest following the SCCM’s guidelines as described in “critical care delivery in the ICU: defining clinical roles and the best practice model” (currently undergoing revision).

We suggest that every ICU have a written ADT policy, as an administrative best practice, to guide appropriate patient placement.

We suggest following the metrics identified as indicators of ADT performance in this framework. This information should be collected electronically through the electronic health record, if available.

We suggest employing the term “nonbeneficial treatment” whenever clinicians consider further care “futile.”

We suggest avoiding the current quantitative definitions of nonbeneficial treatment because of the lack of consensus on a single definition.

We suggest against the routine use of the currently available severity-of-illness scores for identifying nonbeneficial treatments in specific patients.

We suggest that the information provided by healthcare professionals be quantitative to reduce disagreement between the prognostic information delivered to the patients’ surrogates and their understanding and acceptance of the message.

We suggest developing clear ICU and institutional nonbeneficial treatment policies through consensus of all the parties involved (physicians, nurses, administrators, lawyers, ethicists, and family representatives).

We suggest that prudent clinical judgment, in conjunction with the latest American Heart Association guidelines and specific local and hospital policies, be followed in deciding when to withhold or terminate cardiopulmonary resuscitation.

We suggest that life-supportive therapies be removed in cases of patients declared dead by neurological criteria in accordance with local law (including potential legal restrictions associated with the patient’s religious beliefs), hospital policies, and standard medical practice and after appropriate organ donation considerations.

We suggest the early involvement of ethicists (within 24 hr of identifying potential or actual conflict) to aid in conflicts associated with nonbeneficial treatment.

Although palliative medicine consultations have been previously associated with reduction in critical care resources, the most recent evidence does not support a recommendation, emphasizing the need for additional high-quality research on this subject.

We suggest following the SCCM Ethics Committee’s 1997 general recommendations for determining when treatments are nonbeneficial and for resolving end-of-life conflicts regarding withholding or withdrawing life support. We also support the fair-process approach recommended by the American Medical Association’s Council on Ethical and Judicial Affairs committee.

There is growing concern that nonbeneficial treatment affects not only the individuals receiving these treatments but also the rest of the population. Providing nonbeneficial treatments reduces the availability of the same resources in more appropriate situations, treatments, or patients and could cause unwanted and unrecognized harm. The effect of this practice has an unknown effect on the healthcare system as a whole, leading to an urgent need to better understand the impact of misallocation of critical care resources in the U.S. healthcare system.

As a result of the major knowledge gaps identified, we suggest that more research be performed on all aspects of the determination and provision of nonbeneficial ICU treatment.

We suggest adhering to the recommendations of the SCCM Ethics Committee, the Council on Ethical and Judicial Affairs of the American Medical Association, and the Bioethics Task Force of the American Thoracic Society for the ethical allocation of scarce medical resources until updated or appropriate evidence-based operational frameworks become available.

Further research is needed on all aspects of rationing critical care resources to narrow the current gaps in allocating scarce resources.