The Surgeon and the Intensivist: Reaching Consensus in Intensive Care Triage

Stawicki, S. Peter; Pryor, John P.; Hyams, Eli S.; Gupta, Rajan; Gracias, Vicente H.; Schwab, C. William

doi:10.1016/j.jsurg.2007.05.008

« Previous Next »Journal of Surgical Education
Volume 64, Issue 5 , Pages 289-293, September 2007

The Surgeon and the Intensivist: Reaching Consensus in Intensive Care Triage

S. Peter Stawicki, MD
- Division of Traumatology and Surgical Critical Care, Department of Surgery, University of Pennsylvania School of Medicine, Philadelphia, Pennsylvania
- Correspondence: Inquiries to S. Peter Stawicki, MD, Division of Traumatology and Surgical Critical Care, University of Pennsylvania School of Medicine, 3440 Market Street, Philadelphia, Pennsylvania 19104
John P. Pryor, MD
- Division of Traumatology and Surgical Critical Care, Department of Surgery, University of Pennsylvania School of Medicine, Philadelphia, Pennsylvania
Eli S. Hyams, MD
- Department of Urology, New York University, New York, New York
Rajan Gupta, MD
- Division of Trauma, Department of Surgery, Dartmouth—Hitchcock Medical Center, Lebanon, New Hampshire
Vicente H. Gracias, MD
- Division of Traumatology and Surgical Critical Care, Department of Surgery, University of Pennsylvania School of Medicine, Philadelphia, Pennsylvania
C. William Schwab, MD
- Division of Traumatology and Surgical Critical Care, Department of Surgery, University of Pennsylvania School of Medicine, Philadelphia, Pennsylvania

published online 17 September 2007.

Background

Decisions regarding admissions/discharges in the surgical intensive care unit (SICU) can potentially strain the relationship between the critical care team and the primary surgery service. We hypothesized that a multidisciplinary system of arbitration, led by an intensivist, is a safe and workable solution to SICU patient triage, which leads to consensus between critical care team and primary services.

Methods

Demographic, illness severity, readmission, and outcome data were collected prospectively on consecutive patients in a large academic center SICU. Arbitration was directed by an intensivist and a charge nurse, with regular meetings. Representation from various hospital departments (admissions, operating room, nursing, and housekeeping) was included. Decisions on patient discharge from the SICU were compared between the primary service (represented by the Chief resident) and the SICU arbitrator.

Results

A total of 289 patients were admitted to SICU during the 2-month study period, with 952 arbitration decisions. Good agreement exists between the primary service and the arbitrator regarding SICU patient suitability for discharge (Kappa = 0.85). Seventeen patients (5.9%) were readmitted, with 14 (82%) surviving to hospital discharge. None of the readmitted patients was originally discharged over the primary service objection. Day of discharge APACHE II scores of readmitted patients did not differ from those not readmitted (8.2 vs 7.7). Readmissions had longer hospital stays, equivalent SICU stays, and higher mortality (18%) than for patients overall (2.8%).

Conclusions

A dedicated intensivist, supported by a multidisciplinary team, can make arbitration decisions in the SICU that seem to be safe and generally concordant with the primary surgical team of the patient. Additional larger-scale investigation of arbitration in the SICU is warranted.

Key Words: intensive care arbitration, surgical ICU triage, intensivist, agreement, readmissions, complications

Competency: Patient Care, Interpersonal and Communication Skills, Systems Based Practice