ICU Admission, Discharge, and Triage Guidelines

A Framework to Enhance Clinical Operations, Development of Institutional Policies, and Further Research

Joseph L. Nates, MD, MBA, FCCM (Chair); Mark Nunnally, MD, FCCM; Ruth Kleinpell, PhD, RN, FAAN, FCCM; Sandralee Blosser, MD, FCCP, FCCM; Jonathan Goldner, DO, FCCP, FCCM; Barbara Birriel, MSN, CRNP, ACNP-BC, FCCM; Clara S. Fowler, MS; Diane Byrum, RN, MSN, CCRN, CCNS, FCCM; William Scherer Miles, MD, FACS, FCCM; Heatherlee Bailey, MD, FAAEM, FCCM; Charles L. Sprung, MD, JD, MCCM

Disclosures

Crit Care Med. 2016;44(8):1553-1602. 

In This Article

Abstract and Introduction

Abstract

Objectives: To update the Society of Critical Care Medicine's guidelines for ICU admission, discharge, and triage, providing a framework for clinical practice, the development of institutional policies, and further research.

Design: An appointed Task Force followed a standard, systematic, and evidence-based approach in reviewing the literature to develop these guidelines.

Measurements and Main Results: The assessment of the evidence and recommendations was based on the principles of the Grading of Recommendations Assessment, Development and Evaluation system. The general subject was addressed in sections: admission criteria and benefits of different levels of care, triage, discharge timing and strategies, use of outreach programs to supplement ICU care, quality assurance/improvement and metrics, nonbeneficial treatment in the ICU, and rationing considerations. The literature searches yielded 2,404 articles published from January 1998 to October 2013 for review. Following the appraisal of the literature, discussion, and consensus, recommendations were written.

Conclusion: Although these are administrative guidelines, the subjects addressed encompass complex ethical and medico-legal aspects of patient care that affect daily clinical practice. A limited amount of high-quality evidence made it difficult to answer all the questions asked related to ICU admission, discharge, and triage. Despite these limitations, the members of the Task Force believe that these recommendations provide a comprehensive framework to guide practitioners in making informed decisions during the admission, discharge, and triage process as well as in resolving issues of nonbeneficial treatment and rationing. We need to further develop preventive strategies to reduce the burden of critical illness, educate our noncritical care colleagues about these interventions, and improve our outreach, developing early identification and intervention systems.

Introduction

Critical care resources are limited and expensive. The appropriate utilization of ICU beds is essential, but it is complex and a challenge to attain. In 2008, the cost of critical care in the United States was estimated to range between $121 and $263 billion (16.9–38.4% of hospital costs and 5.2–11.2% of national healthcare expenditures).[1] The increasing cost of delivering healthcare has become an unsustainable burden accompanied by waste, overuse, care delays, and other delivery inefficiencies.

In 1998, the Advisory Commission on Consumer Protection and Quality in the Health Care Industry, created by President William J. Clinton to evaluate and provide advice on the healthcare system, released a report asking for a national commitment to improve the quality of healthcare.[2] Consequently, the Institute of Medicine released recommendations for improving the 21st century American healthcare system, emphasizing the delivery of safe, effective, patient-centered, timely, efficient, and equitable healthcare.[3,4] The institute proposed an urgent overhaul of the healthcare system; it was considered imperative that the management of our systems be improved. As time has passed, the increasingly older and growing population, limited workforce, increased complexity of care and severity of illness of hospitalized patients, and other factors are adding to the pressure to change clinical processes to improve patient care.

Preceding some of these reports, in 1999, the Society of Critical Care Medicine (SCCM) published guidelines for ICU admission, discharge, and triage (ADT).[5] Since that time, practitioners and administrators have considered these guidelines in formulating policies and establishing criteria for ICU ADT in their institutions. In light of the significant healthcare legislative changes and changes in ICU technologies and treatments that have occurred in the United States in the 15 years since the original ADT guidelines were published, the American College of Critical Care Medicine Board of Regents, through the Guidelines Management Committee, appointed a new Task Force to re-evaluate and update the guidelines.

The following recommendations are the result of the work of the ADT Task Force. The recommendations are divided into sections: admission criteria and benefits of different levels of care, triage, discharge timing and strategies, use of outreach programs to supplement ICU care, quality assurance/improvement and metrics, nonbeneficial treatment in the ICU, and rationing considerations and systems.

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