EMERGENCY TRIAGE TO INTENSIVE-CARE - CAN WE USE PROGNOSIS AND PATIENTPREFERENCES

OBJECTIVE: To identify predictors of 6-month mortality known before em ergent admission to intensive care (IC) and to describe obstacles to t he use of patient preferences in emergency triage decisions. DESIGN: H istorical cohort SETTING: A 600-bed university hospital PATIENTS: 263 consecutive patients triaged in the emergency room to receive intensiv e care MEASUREMENTS AND MAIN RESULTS: Medical records were abstracted for age, performance status, and chronic disease severity as predictor s of 6-month survival. Acute Physiology Score (APS) in the emergency r oom was used as a measure of acute illness severity. Deaths during the 6 months following IC admission were determined from record review an d death certificate data. Obstacles to communication of patient treatm ent preferences at the time of triage were described. Six-month mortal ity was 19 percent, and increased with increasing APS, age greater tha n or equal to 80 (43%), poor performance status (56%), and severe chro nic disease (33%) (P less than or equal to 0.01). In multivariate anal ysis, APS, age greater than or equal to 80 and performance status were independent predictors of 6-month mortality. Only APS predicted morta lity in hospital. The most common obstacles to use of patient preferen ces in triage decisions were absence of documented advance directives (95%) and the brief duration of acute illness (72%). Mental status cha nges were very common in the emergency room for nonsurvivors (61%), bu t chronic cognitive impairment was rare (3%). CONCLUSIONS: Patients wi th poor performance status or very advanced age have increased mortali ty within 6 months of emergent triage to IC. Mental status changes, ab sence of advance directives, and time constraints are common barriers to communication of patient preferences at the time of triage. Primary care physicians need to elicit and record patients' preferences befor e the time of emergent decisions about IC.