Telephone triage for a liver intensive care unit – advise or admit?

Objective

To determine the referral pattern and organ dysfunction severity of interhospital consultations, and triage practice at a specialised liver intensive therapy unit (LITU).

Methods

A prospective audit was conducted from 1 March to 30 November 2006, for all interhospital telephone referrals to our 15-bed LITU as recorded on a standardised proforma. Data evaluated were: referral diagnoses; reasons for refusal to LITU ('too well to benefit', 'too sick to benefit' or 'no beds'); triaged destination of care ('ward' at referral hospital or our hospital liver ward, 'IC' at referral hospital high-dependency unit/ICU or 'LITU'); and parameters for Sequential Organ Failure Assessment (SOFA) score.

Result

A total of 620 calls were received for 439 referrals (37% during the 17:00–24:00 hours period, 11% during 00:00–08:00 hours), with 38% from the London region. Drug-induced acute liver dysfunction/failure (ALDF) was the most common reason for consultation (39%), with paracetamol being most common (163/172), most of whom were triaged to a referral hospital ward (63% vs 14% to LITU). Patients with diagnosis of 'ischaemic hepatitis' tended to be triaged to IC (82%), and pancreatobiliary disease and trauma to the LITU (69% and 80%).

Of the patients not admitted to our LITU (162 to ward and 176 to IC), 79% were deemed too well to benefit and 2% due to no beds. the mean ± SD SOFA score for the too sick to benefit group (19%) was 11.5 ± 4.3 (63% had decompensated chronic liver disease (d-CLD), 36% with malignancy, major sepsis or morbid cardiocerebral event). The mean ± SD SOFA scores for the ward, IC and LITU groups were 2.5 ± 2.4, 7.9 ± 4.6 and 7.8 ± 4.5, respectively. The SOFA liver score was highest in all three triage groups, overall mean of 2.3 (ward, 1.9 ± 1.4; IC, 2.6 ± 1.2; LITU, 2.4 ± 1.2), compared with other components (respiratory 0.9, cardiovascular 0.7, coagulation 0.9, renal 1.1, central nervous system 0.8). Patients with INR > 6 were more likely to be triaged to LITU (OR 4.2).

A total of 97 patients were admitted to our LITU (five of 17 patients triaged at referral to our hospital liver ward); six patients died before arrival and three patients were diverted to another liver intensive care facility for family convenience. Fifteen patients underwent liver transplantation (10/49 with ALDF, 5/37 with d-CLD). Mortality in the LITU group was 36%, and highest with d-CLD (57% vs 25% with ALDF). Mean referral, post-transfer and 48-hour SOFA scores of LITU nonsurvivors were 10.7, 12.7 and 13.9, respectively (6.5, 7.7 and 7.5 for survivors).

Conclusion

The refusal rate to our LITU due to no beds was low. Paracetamol remains a common cause for drug-induced liver injury, although few are severe cases. The triage decision appeared to be influenced by the INR, d-CLD with or without a reversible cause and the presence/absence of morbid extrahepatic diagnoses.