Pandemic triage: clipboard medicine or evidenced based?

Introduction

The World Health Organisation states that it is not a case of if, but when, the next influenza pandemic strikes. In the event of a pandemic, intensive care resources are predicted to be overwhelmed [1]. One means of allocating and maintaining ICU support is the triage protocol developed by Christian and colleagues [2] based on the Sequential Organ Failure Assessment score, comorbidity, and age. This study assesses the efficacy of the triage criteria on all patients admitted to our 28-bed ICU.

Methods

Data required to apply the triage protocol were collected for consecutive critical care admissions over a 60-day period. Triage categories were assigned as per the protocol and the outcome data were collected from the hospital patient data system.

Results

Of the 255 admissions, 190 were nonelective. Of these, the triage category was blue (that is, would have been refused admission to ICU) on admission for 32, and a further 29 who were not (that is, were deemed appropriate ICU admissions by the triage protocol) became blue by 48 hours. Of these 61 patients, 29 were discharged from hospital alive. For our sample of emergency admissions, the sensitivity of the triage protocol for correctly identifying patients at admission who survive to hospital discharge was 0.87. The corresponding specificity was 0.27.

Conclusion

Thirty-two per cent of emergency admissions would have been denied critical care using the triage protocol, of which 48% survived to hospital discharge. We conclude that the triage criteria are not fit for purpose: they are neither sensitive nor specific enough to differentiate survivors from nonsurvivors, and would still leave clinicians with too many patients for too few beds.