Society of Critical Care Medicine (SCCM)

Guidelines for ICU Admission, Discharge and Triage (1999)

http://www.sccm.org/professional_resources/guidelines/table_of_contents/Documents/IC
U_ADT.pdf

This statement outlines models for ICUs to use in formulating admission discharge and
triage criteria. The purpose of the statement is to guide decisions regarding appropriate
use of ICU services in the context of containing health care expenditures.

Main points:
ICUs should create policies specific to their unit.
• They should contain:
o explicit criteria for admission and discharge
o scope of services it provides
o patient population it serves
o specific circumstances under which the patients are admitted
• Guidelines and implementation policy should be written by a multiprofessional
team
o Policies should be overseen and updated by an ICU Committee
o Policies should be revised as needed, based on objective data
o Compliance should be monitored
• Policies should include plans for accommodating admissions when unit capacity
is reached
• Admission, discharge and triage criteria should recognize patient autonomy,
including advance directives, living wills or durable powers of attorney for health
care decisions
• Should include who can admit patients to the ICU

Admission Criteria
• ICU admission criteria should select patients who are likely to benefit from ICU
care. ICU care has been demonstrated to improve outcomes in severely ill,
unstable patient populations.
• ICU practitioners should understand tools for assessing severity of illness and
prognosis of critically ill patients.
• Existing predictive instruments have only been applied to patients already
admitted to an ICU and have not been tested as preadmission screening tools.
• Both extremes of the risk of death spectrum are not ideal ICU patients: those “too
well to benefit” and those “too sick to benefit.”
o Defining these groups may be difficult solely based on diagnosis
o Criteria defining “substantial benefit” are subject to interpretation

The authors present 3 models for defining those that will benefit most from the ICU, and
give clinical examples of patients and conditions that can be separated based on the
parameters of each model.
Prioritization Model
Priority 1: unstable patients in need of intensive treatment and monitoring that cannot be
provided outside of the ICU.
This includes ventilator support and vasoactive drug infusions. Priority 1 patients have
no limits placed on the extent of therapy they are to receive.

Priority 2: patients requiring intensive monitoring and potential for immediate

intervention
No therapeutic limits are stipulated for these patients.

Priority 3: unstable critically ill patients who have a reduced likelihood of recovery
because of underlying disease or the nature of their acute illness
Patients may receive intensive treatment to relieve acute illness but limits on therapeutic
efforts may be set, such as no intubation or resuscitation.

Priority 4: patients who are generally not appropriate for ICU admission
Admission of these patients should be on an individual basis, under unusual
circumstances and at the discretion of the ICU director. These fall into two categories:
• Too well to benefit based on low risk. Examples given are patients after
peripheral vascular surgery, hemodynamically stable diabetic ketoacidosis, mild
congestive heart failure, conscious drug overdose
• Too sick to benefit based on condition consistent with imminent death. Examples
given are patients with severe irreversible brain damage, irreversible multi-organ
system failure, metastatic cancer unresponsive to therapy, patients with decision-
making capability who decline services typically provided by ICUs, comfort care
only.

Diagnosis Model

This model uses specific conditions or diseases to determine appropriateness of ICU

admission. This model is a list of clinical conditions by body system with indicators of
clinical severity.

Objective Parameters Model

Includes parameters of vital signs, laboratory values, radiological and other testing results
that are consistent with severity of illness that may be helpful criteria for assessing
usefulness and necessity of ICU services.

Discharge Criteria
ICU policies should stipulate objective criteria for determining when patients can be
discharged from the ICU.
• Objective evidence of improvement or stabilization demonstrating no further
benefit that could not be provided in a non-ICU stetting
 • Objective evidence of deterioration and no further active intervention is planned
• Should be similar to the admitting criteria for the level of care to which the patient
is being transferred

Triage Criteria
• Often needed because the number of potential ICU patients exceeds the available
beds
• May use the same prioritizing criteria listed under admission
• ICU/Critical Care Director should have the authority and responsibility to triage
• Triage decisions may be made without patient/surrogate consent
• Triage decisions may be made despite an anticipated untoward outcome

Summary of points potentially applicable to VALUE participants:

• ICUs should have protocols for admission, discharge and triage
• Criteria for admission, discharge and triage should be based on elements known
to be influenced by ICU care. Some patients are too well to need ICU services,
and some are too sick to benefit.
• The ICU/Critical Care Director has authority and responsibility over these
protocols/criteria and their enforcement, and is therefore probably an important
champion to recruit for this work.
• There are many severity/prognostic scoring tools, and ICU personnel should be
familiar with them.
• None of the 3 models for determining ICU ‘appropriateness’ given in this
guideline specifically use age as an element for guiding decisions.