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CONCORDANCE BETWEEN INTENSIVISTS IN CRITICAL CARE TRIAGE FREE TO VIEW

Sudhir Krishnan, MD; Aishwarya Palwai, MD; Ziad S. Shaman, MD*
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Case Western Reserve University (MetroHealth), Cleveland, OH


Chest


Chest. 2008;134(4_MeetingAbstracts):s49001. doi:10.1378/chest.134.4_MeetingAbstracts.s49001
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Abstract

PURPOSE:Intensivists’ triage decisions are complex and depend on the patient’s condition and on resource availability. As critical care resources are limited and patient conditions are usually complicated, these decisions should be made by the most senior officer, and with highest concordance. We tested agreement in triage decisions between Intensivists and the role of seniority.

METHODS:At an urban academic institution, 2 Critical Care Fellows triaged patients to one of 4 levels of care: Medical Intensive Care Unit (MICU), Step Down (SD) Unit, Telemetry, and General Floor. The data used to triage each case were deidentified and presented to 9 Intensivists (5 Critical Care Attendings, and 4 Fellows) at the same institution to re-triage. The Intensivists were blinded to each other and to the original triage decisions. The Intensivists assumed no resource limitations. Agreement between Intensivists was evaluated by calculating Cohen’s kappa and Intraclass Correlation Coefficient (ICC).

RESULTS:150 triages were recorded. In 67, one or more Intensivist indicated the need for more information. The other 83 cases were considered complete by all 9 Intensivists. There was moderate agreement between Intensivists (average kappa .263, ICC .331). The agreement improved slightly when incomplete cases were excluded (average kappa .337, ICC .423). Perfect agreement was seen in 19 of the 50 patients admitted to the MICU. All 19 patients were invasively ventilated or on vasopressors. The worst agreement was seen in admissions to the SD unit (ICC 0.097). Agreement between the Attendings as a group (average kappa .174, ICC .282) was not better than agreement between the Fellows as a group (average kappa .274, ICC .365).

CONCLUSION:In this study, there was at best a moderate agreement between Intensivists on triage decisions. Consensus existed only when a patient was receiving invasive ventilatory or vasopressor support. The worst agreement was seen in triage decisions regarding the SD unit. Seniority did not seem to improve agreement.

CLINICAL IMPLICATIONS:Lack of agreement in triage may result in adverse patient outcomes. Triage criteria should be defined.

DISCLOSURE:Ziad Shaman, None.

Tuesday, October 28, 2008

2:30 PM - 4:00 PM


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