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The term triage originates from the French verb trier, meaning to sort. Its medical usage dates from the Napoleanic Wars when a Hôpital de Triage was employed as a sorting station for injured soldiers. In modern hospitals triage is the process of determining the most appropriate disposition for a patient based on the nature and severity of their illness and on hospital resources. Triage typically includes a decision about whether to admit a patient to the hospital and if so, to which clinical area and service (eg, Hospital Medicine, Surgery).
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Triage complexity increases with increasing illness severity; thus patients being considered for ICU admission can present a particular challenge. Nationally accepted guidelines for ICU admission do not exist, and mortality prediction models such as the Acute Physiology and Chronic Health Evaluation IV (APACHE IV), Mortality Probability Models II (MPM II), and Simplified Acute Physiology Score (SAPS II) unfortunately have poor utility in predicting which patients should be admitted to an ICU, since all of these prognostic models were developed based on patients already in the ICU.
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The most widely used framework for determining the appropriateness of ICU admission is based on the Society of Critical Care Medicine's (SCCM) Guidelines for intensive care unit admission, discharge, and triage, published in 1999. These guidelines implicitly acknowledge the difficulties in triaging critically ill patients by proposing three different models based on patient prioritization, diagnosis, or objective parameters. The prioritization model divides patients into four categories: those who need intensive monitoring and treatment (most often those requiring vasoactive drugs or mechanical ventilation), those who need intensive monitoring and may need immediate intervention, patients who are unstable but have a reduced likelihood of recovery, and those who are too well or too sick to benefit from intensive interventions.
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Whatever model or combination thereof is used, explicit written institutional policies must exist in order to avoid confusion and to encourage consistency of practice. These policies should be made public and discussed with critically ill patients or their surrogates. Administration, nurses, support staff, and physicians should collaborate on institution-specific policies regarding ICU use. Overflow policies must also be clearly defined and readily available. The hospital should assign triage responsibilities to a single individual, with performance overseen by a multidisciplinary critical care committee. This committee should have oversight of all of the hospital's ICUs and their directors and should regularly review ICU denials and ICU rapid return or rapid readmission patients.
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The Ethics Committee of SCCM in their Consensus Statement on the Triage of Critically Ill Patients states that providers of critical care must use some moral framework for distributing limited resources efficiently and equitably, since demand will frequently exceed supply. By necessity, in an equitable system ICU care must be restricted. Decisions should be based on the concept of medical justice, such that limited resources are allocated to those most likely to benefit from their use. Such patients should have a reasonable expectation of substantial recovery, as recommend by the Consensus Statement. Patients who are not expected to benefit should be excluded. That includes both the too-well-to-benefit and too-sick-to-benefit categories. The too-sick-to-benefit category includes not only those with end-stage chronic disease but those with irreversible conditions such as metastatic cancer unresponsive to chemotherapy, severe ischemic or anoxic brain damage, and irreversible multiorgan failure. When a patient has become critically ill with a chronic disease the desirability of ICU care should be discussed with the ICU director, the EM physician, and the patient's family at the time of initial presentation. This discussion should include specific reference to triage policies.
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The role of the ICU director, often a critical care trained intensivist, should be separated from that of the triage clinician as much as possible to avoid conflicts of interest. SCCM also recommends that the ICU director have no other clinical responsibilities.
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Triage of Surgical Patients
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For the sake of expediency hospitalists are sometimes asked to fill the gaps when providers in certain specialties are not immediately available or responsive to ED needs. Particularly common is the request by EM physicians to hospitalists to admit patients with surgical problems. Despite the increasing trend for such admissions, hospitalists often fear legal liability when managing patients with a primary surgical diagnosis. Hence, triage decisions for patients potentially needing surgery should follow the simple principle of placing the patient on the service where the patient will receive the most appropriate care. Oftentimes, this determination can only be made once both surgeons and hospitalists have made an in-person evaluation of the patient. In addition, the role of nursing should not be overlooked. Patients with a primary surgical diagnosis may benefit more from the care provided by surgical nurses, irrespective of who is the attending of record. Likewise, patients with a primary medical diagnosis driving admission may benefit more from the care provided by medical nurses, even if it is anticipated that they will eventually require surgery.
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When the decision is made for a patient to be co-managed by surgery and Hospital Medicine, roles and responsibilities of each service must be agreed upon at the outset of care. Are the patients going to be truly co-managed where each service has the authority to write orders? or is one service or the other going to act strictly as a consultant making recommendations only? Hospital policies for the delineation of responsibilities for such patients are essential. A case-by-case approach burdens the EM physician with multiple phone calls and slows throughput. One solution that may permit more immediate evaluation and management by surgeons involves use of acute care surgeons (surgeons who spend their time caring for hospitalized patients, sometimes called surgical hospitalists or surgicalists).
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Disease-Specific Considerations
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Disease-specific prediction models are more accurate than general guidelines in predicting need for ICU admission. Specific criteria exist only for a few medical conditions, such as gastrointestinal hemorrhage (the BLEED criteria) and pneumonia (CURB-65, Pneumonia Severity Index, SCAP score). A hospitalist should incorporate these prognostic criteria or guidelines into practice when applicable. Sepsis remains a common and life-threatening reason for presentation to the ED. Extremely common, simple sepsis is associated with low to moderate mortality risk (˜16%), and may require ICU admission at presentation, but in many cases may be safely managed in the non–critical care setting. On the other hand, severe sepsis (sepsis associated with end-organ damage or hypotension) and septic shock (severe sepsis with hypotension and tissue hypoperfusion unresponsive to significant volume challenges) have an associated mortality of approximately 30% and 50%, respectively. These latter two groups of patients have unstable physiologic or hemodynamic parameters and should be admitted to the ICU, barring unusual circumstances.
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The Institute of Medicine's 2007 report, The Future of Emergency Care: Hospital Based Emergency Care at the Breaking Point, offers several suggestions to improve the efficiency of hospital-based emergency care. The use of “Observation Units” or “Clinical Decision Units” to manage patients following their initial ED evaluation allows additional time to perform diagnostic studies or discreet time-limited management according to specific entry criteria. Such additional time can help determine the need for inpatient admission or early discharge.
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Observation patients are defined by the Centers for Medicare and Medicaid Services (CMS) as those patients needing further evaluation “to determine the need for inpatient admission.” CMS explicitly states that most patients will require less than 24 hours to reach this goal. Alternatively, admission review guidelines such as those published by InterQual define inpatient or observation status. By design InterQual guidelines review patient criteria for admission on a retrospective basis, whereas the CMS policy evaluates patient admission criteria prospectively. Observation patients may be best understood when considering patient lengths of stay. The Centers for Disease Control and Prevention (CDC) has reported that admitted ED patients will spend roughly five hours in the ED. Hospitals are often scrutinized for inpatient admission of one day or less, as many of those patients should have been classified as “observation” status, even though they occupy an inpatient bed.
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There remains a distinct group of ED patients who clearly need more than 5 hours, but less than 24 hours, to address their clinical needs. These are the “6- to 24-hour” patients. Several prospective, randomized, controlled trials have shown that the length of stay and costs of these patients will double or triple if they are admitted to a traditional inpatient ward rather than an observation unit. Such patients will exacerbate ED overcrowding if they complete their evaluation in the ED, and they cannot be discharged without potential risks. A dedicated observation unit for appropriately selected patients can improve patient satisfaction, lower rates of missed myocardial infarction, lower diagnostic uncertainty, decrease ED and hospital overcrowding, improve diagnostic test completion rates, and maintain clinical outcomes comparable to those for patients admitted to the hospital.
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While observation units have been around nearly as long as EDs, it is only in the last two decades that protocol-driven units have been described. Initially units were primarily focused on patients with chest pain, subsequently giving rise to “chest pain centers.” Based on clinical studies, observation units have expanded into protocols for asthma, syncope, heart failure, atrial fibrillation, and transient ischemic attacks. By design observation units are also well equipped to manage patients with dehydration, abdominal pain, renal colic, and a variety of infections. Nationally, 31% of U.S. hospitals either utilize or plan to implement an observation unit. The observation unit truly represents an interface between EM and Hospital Medicine. Fifty-three percent of observation units are geographically located within or adjacent to the ED, with the remainder either in the hospital or in both locations. Admission privileges to the unit may be “open” to any hospital physician, or “closed” and limited to only one specialty group. That group may be the EM group or Hospital Medicine group, depending on local practices. Regardless of the model, Hospital Medicine and EM need to collaborate to optimize clinical care and patient flow. Some units operate as a “hybrid” unit, caring for observation patients as well as scheduling outpatient procedure patients. This model offers the advantage of a more robust unit census, with observation patients filling the unit during the evening hours, and scheduled procedure patients filling the unit during daytime hours. This model has also been shown to improve nurse utilization for a smaller unit (3.7 vs 2.5 patients/nurse/hour).
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Basic principles for the operation of an observation unit have been described by ACEP. Because the unit is designed for this specific patient population, its use should ideally be limited to patients with a well-defined reason for observation, or a working diagnosis or condition. That condition may involve a diagnostic evaluation for a potentially serious diagnosis, therapy of an acute medical condition, or management of acute psychosocial needs. Diagnostic conditions should represent a balance between the potential morbidity and mortality of the condition and the probability that the condition will be confirmed. For example, evaluation of patients with chest pain for possible acute coronary syndrome (ACS), which (if diagnosed) bears a 25% short-term adverse outcome likelihood, is often limited to patients with lower probability of disease (7% or less).
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The patient's severity of illness and intensity of service requirements should be low enough to match the resources available in the observation unit. Patients actively managed in observation units have an average length of stay of 15 hours. Units are often located within or adjacent to the ED since most patients arrive from the ED. When units are remote from the ED, it becomes logistically difficult for ED physicians to participate in the care of the patient. On average, observation units are staffed with one nurse per four patients, and 20% of such units employ nurse practitioners or physician assistants. Care is best facilitated through the use of guidelines for both unit operations and the management of specific conditions developed through background research and collaboration with other relevant departments. Condition guidelines often include inclusion and exclusion criteria, interventions permitted in the observation unit, and criteria for discharge or hospital admission. From these guidelines, protocol orders may be developed. Since the observation unit functions as a limited resource within the facility and may be used as an alternative to admission, its use, processes, and outcomes require intensive and frequent review for utilization and quality. Utilization may include census, case mix, length of stay, and admission rate. Quality audits may include protocol use rates, patient satisfaction, ED or hospital return visits, hospital admission rates, ICU admission rates, and mortality. Finally the observation unit should remain cost effective and efficient for the hospital, providers, and patients.