Impact of a pandemic triage tool on intensive care admissions; poster presented at the Asia Pacific Critical Care Congress. Sydney, Australia, 30th October – 2nd November 2008.

1. Impact of a Pandemic Triage Tool
on Intensive Care Admissions
CANBERRA A Bailey, I A Leditschke, J Ranse, K Grove
H O S P I TA L
A division of ACT Health Intensive Care Unit, Canberra Hospital, Canberra, Australia.
InTRoduCTIon
During a pandemic, health care services are likely to become quickly overwhelmed. Figure 2: Initial SOFA score assessment
Emergency departments will need to triage patients on presentation to ensure that the
greatest good is achieved for the greatest number of patients. This triage principle also Traige code Criteria Action or priority
applies to other hospital services that may experience a demand for their services, such Highest priority
as the intensive care unit [ICU]. Recently there has been increased interest in pandemic Red SOFA score ≤7 or single-organ failure
preparedness and the use of critical care resources during a pandemic1.
Yellow SOFA score 8 – 11 Intermediate priority
Various triage tools have been developed to assist in the clinical decision making of ICU
·Defer or discharge
resource provision for critically unwell patients during a pandemic2,3. However, to date GReen No significant organ faiure
·Reassess as needed
these tools have not been applied to a ‘real’ patient population.
·Manage medically
Blue Exlusion criteria met or SOFA score >11 ·Provide palliative care as needed
·Discharge from critical care
Figure 1: Inclusion / Exclusion criteria
Inclusion criteria Exclusion Criteria
Figure 3: 48-hour and 120- hour assessments
A. Requirement for invasive ventilatory A. Severe trauma
support B. Severe burns of patient with any 2 of the Traige code Criteria Action or priority
I. Refactory hypoxemia (SpO2 following:
< 90% on non-rebreather mask • Age > 60 yr
Red SOFA score <11 and decreasing Highest priority
or FiO2 >0.85) • > 40% of total body surface area
II. Respiratory acidosis (pH < 7.2) affected
III. Clinical evidence of impending • Inhalation injury Yellow SOFA score stable at <8 with no change Intermediate priority
respiratory failure C. Cardiac arrest
IV. Inability to protect own airway • Unwitnessed cardiac arrest GReen No longer dependent on ventilator ·Discharge from critical care
• Witnessed cardiac arrest, not responsive
B. Hypotension (systolic blood pressure to electrical therapy (defibrillation or Blue Exclusion criteria met or SOFA score >11 or ·Provide palliative care as needed
< 90 mm Hg or relative hypotension) pacing) (48-houR) SOFA score stable at 8-11 with no change ·Discharge from critical care
with clinical evidence of shock (altered • Recurrent cardiac arrest
level of consciousness, decreased D. Severe baseline cognitive impairment Blue Exlusion criteria met or SOFA score >11 or • Provide palliative care as needed
urine output or other evidence of end- E. Advanced untreatable neuromuscular disease (120-houR) SOFA score <8 with no change • Discharge from critical care
organ failure) refractory to volume F. Metastatic malignant disease
resuscitation requiring vasopressor G. Advanced and irreversible
or inotrope support that cannot be immunocompromise
managed in ward setting H. Severe and irreversible neurological event or
condition Figure 4: Application of triage tool to ICU admissions
I. End-stage organ failure meeting the following
criteria:
Total number of patients
Heart
• NYHA class III or IV heart failure
Lungs
• COPD with FEV1 < 25% predicted, Meets initial inclusion criteria
baseline PaO2 < 55 mm Hg, or
secondary pulmonary hypertension
• Cystic fibrosis with postbronchodilator 48 -hour inclusion criteria re-assessment
FEV1 < 30% or baseline PaO2 < 55 mm
Hg
• Pulmonary fibrosis with VC or TLC
< 60% predicted, baseline PaO2 < Meets exclusion criteria
55 mm Hg, or secondary pulmonary
hypertension
• Primary pulmonary hypertension with Initial assessment
NYHA class III or IV heart failure, right
atrial pressure > 10 mm Hg, or mean
pulmonary arterial pressure > 50 mm Hg
Liver 48-hour assessment
• Child–Pugh score ≥ 7
J. Age > 85 yr
K. Elective palliative surgery 120-hour assessment
MeThods dIsCussIon
We performed a retrospective observational study of the application of the pandemic Use of this triage tool creates substantial surge capacity when applied to our usual
triage tool described by Christian et al2 [Fig. 1], to all admissions to our 14 bed general ICU patients. However, whether the tool will provide sufficient surge capacity in an
medical-surgical ICU over a 4 week period in February 2007. actual pandemic is untested. Careful management of community expectations may be
required to implement the tool, as most patients currently admitted to our ICU would be
excluded.
ResulTs
The tool aims to identify patients that will most benefit from admission to the ICU
119 patients were admitted over the study period with a mean age of 60 years (range 1- and excludes patients considered to be “too well”, “too sick” or with co-morbidities
89) and a mean ± standard deviation APACHE II score of 14.88; ± of 7.95 (range 4-47). likely to limit survival in the shorter term2. The data we have presented generate
Figure 4 demonstrates the application of the triage tool to this sample. serious questions about the appropriateness of our current use of ICU resources and
are consistent with the health care spending data demonstrating that a substantial
On admission only 23.5% (n=28) met the triage inclusion criteria, whilst 76.5% (n=91) proportion of health care resources are consumed in the last year of life4.
of these patients did not meet the triage inclusion criteria. The excluded patients were
reassessed at 48 and 120 hours. At this point an additional 1 patient was included. Testing of the tool in other ICUs would be useful, as the data generated could be used
to facilitate community discussion about likely differences in ICU management in a
The exclusion criterion was then applied to the included 24% (n=29) patients. Following pandemic situation and may also aid the identification and comparison of differences in
this, only 10% (n=12) patients from original 119 qualified for further application of the resource management between ICUs.
triage tool.
References
1. Challen K, Bentley A, Bright J, Walter D. Clinical review: mass casualty triage-pandemic influenza and critical care. Critical Care 2007;11:212.
The remaining 10% had the sequential organ failure assessment [SOFA] score applied. 2. Christian MD, Hawryluck L, Wax RS, et al. Development of a triage protocol for critical care during an influenza pandemic. CMAJ 2006;175:1377.
From this, 1 of the 12 patients was deemed “too sick” and recommended for palliation, 3. Talmor D, Jones A, Rubinson L, Howell MD, Shapiro NI. A simple triage scoring system predicting death and the need for critical care resources for use
during epidemics. Crit Care Med 2007;35(5):1251-1256.
therefore leaving 9.2% (n=11) patients who ICU management was deemed appropriate. 4. Barnato A. End-of-life spending: can we rationalise costs? Critical Quarterly 2007; 49(3):84-92.