Civilian triage in the intensive care unit: the ritual of the last bed.

OBJECTIVE: To evaluate the numerous problems that exist when there is an acute shortage of trained critical care nurses, no triage officer is available or designated, there is no cooperation among intensive care units (ICUs) or alternative sites, or there is excessive political or financial pressure applied to maintain a referral practice or to fill all the beds, or limited ability to divert ambulances to other hospitals. The Joint Commission on Accreditation of Health Care organizations now mandates a written policy: "when patient load exceeds optimal operational capacity" (1992).

DATA SOURCES/STUDY SELECTION: Selected clinical, philosophical, and public policy literature on the subject of triage. DATA SYNTHESIS/DATA EXTRACTION: 1) An ICU medical director, designee, or supervisory nurse should be empowered as the gatekeeper/triage officer. 2) The basis for regulating admission, discharge, or triage from the special care unit should be medical suitability (from a utilitarian or egalitarian point of view). During high-level triage when all ICU patients are receiving active therapy, these decisions should override the individual primary physician-patient relationship. 3) The guidelines should follow the "congestive heart failure" treatment analogy: a) preload reduction: hold high-risk patients in the postanesthesia care unit or Emergency Room, postpone surgery, hold transfers in outlying ICUs; b) improve cardiac performance: increase efficiency and decrease workload per patient by performing fewer invasive procedures and transporting fewer patients for abdominal computed tomography scans; c) afterload reduction: keep unstable patients in the postanesthesia care unit, send sicker patients to intermediate care units, send "stable" ventilator-dependent patients to general medical/surgical units, and transfer or resolve issues regarding "hopeless" patients.

CONCLUSIONS: It is necessary to have public disclosure of the broader issues related to high-level triage. The first issue is recognition that there are periods of time when ICU capacity is exceeded or skilled critical care nurse availability is reduced. The next issue is the decision of who is best suited to make complex and dynamic triage decisions and what kind of oversight should be provided. Other issues relate to whether there should be patient or family consent, and what to do about patients receiving marginal benefit or who are considered hopeless or unsalvageable, yet the family or surrogate decision maker (or perhaps one of the consultants) wants to continue active care in the ICU. In the conflict between individual and community rights and benefits, there should be a nonlitigious approach when a patient is harmed during these periods of high census or limited capacity. In recognition of these complex issues (including potential conflicts among ICUs, hospital administration, individual physicians, and the various medical and surgical programs feeding patients into special care units), the Society of Critical Care Medicine has organized a Task Force on the legal and ethical justification for triage.