To admit or not to admit? The suitability of critical care admission criteria

Introduction

During the 2010/2011 winter the H1N1 influenza pandemic placed increased demand on critical care services, prompting our department to devise a modified triage tool for the ICU to be implemented at a time of exceptional bed crisis [1]. Scoring systems such as APACHE or Sequential Organ Failure Assessment (SOFA) have been used to predict mortality and optimize critical care service utilization [2]. This audit aimed to validate our triage tool for patients admitted to the ICU.

Methods

We retrospectively examined patient notes for all admissions to our adult ICU during December 2010 and January 2011. Patient admission criteria (SpO₂ <90% on FiO₂ >85%, respiratory acidosis pH ≤7.2, respiratory failure or airway compromise, systolic pressure <90 mmHg, SOFA score ≥7) or refusal criteria (SOFA score ≥12, severe trauma, unwitnessed or non-VF arrest, severe life-limiting condition) were recorded with outcome data.

Results

We analysed 27 sets of notes. Twenty-two patients (81%) fulfilled at least one admission and no refusal criteria. Two patients (7%) had documented refusal criteria. The first of these had a severe life-limiting condition, staying 29 days in the ICU and a further 65 days in hospital. The second was admitted post non-VF arrest, dying after 2 days in the ICU. Three patients (11%) met no admission criteria. These patients stayed between 4 and 6 days in critical care with total hospital stays of 18 to 98 days, one requiring 30 days of rehabilitation.

Conclusion

The proposed admission criteria concurred with clinical decision-making in 81% of admissions. The patients that met refusal criteria required either prolonged hospital stay or had short survival times and may not represent optimal utilization of critical care facilities during a time of increased demand. Those patients not meeting the admission criteria had short critical care stays illustrating that rigid admission requirements may exclude patients who could benefit from critical care. A standardized set of admission criteria may supplement decision-making during times of increased critical care demand and strengthen documentation of those decisions. However, no set of criteria can replace clinical judgement in critical care admission.