ICU Triage in the Elderly
Will a system of standardized referral for intensive care unit (ICU) admission provide long-term benefit for critically ill elderly patients?
Participants in this cluster randomized clinical trial included patients at 24 hospitals in France who presented to the emergency department with any of several pre-established critical conditions and who were ≥75 years old, free of active cancer, and had preserved functional and nutritional status. A standardized ICU referral process was implemented at 11 hospitals in the intervention group, and usual ICU referral practice continued at 13 hospitals in the control group. Primary outcome was overall mortality at 6 months; secondary outcomes were ICU admission rate, in-hospital mortality, functional status at 6 months, and quality of life at 6 months.
The ICE-CUBII (Impact on Mid-term Mortality of Guidelines for ICU Admission of Elderly Patients Arriving in Emergency Departments) trial enrolled 3,037 patients with pre-established critical conditions: respiratory failure, shock, arrhythmia, chronic heart failure requiring respiratory support, coma, gastrointestinal hemorrhage, pancreatitis, hepatic failure, acute abdomen, acute kidney failure, major surgery, multiple trauma, and “other.” The average age of enrolled patients was 85 years. The intervention group had higher severity of illness at time of admission. The most frequent initial clinical diagnoses were: septic shock, acute respiratory failure, severe pneumonia, and cardiac insufficiency requiring respiratory support. For all qualified patients, protocol in the intervention group required the emergency departments physician to call the ICU attending physician, who would then evaluate the patient at bedside. The emergency department and ICU physicians would then jointly decide whether ICU admission was warranted, with consideration of the opinion of the patient or surrogate decision-maker. Overall mortality at 6 months was 45% in the intervention group and 39% in the control group (p < 0.001). The difference was not significant (p = 0.28) after adjustments for baseline characteristics: illness severity, initial diagnosis, patient age, ICU admission time, emergency department physician seniority, baseline functional status, living situation, and home support. ICU admission rate was higher in the intervention group (61% vs. 34%, p < 0.001), as was in-hospital mortality (30% vs. 21%, p < 0.001). Both findings remained significant after adjustment for baseline characteristics. Functional status at 6 months declined more for the intervention group; after adjustment, the difference was not significant. Physical quality of life at 6 months was not significantly different; mental health-related quality of life was higher in the intervention group but did not meet criteria as a clinically important difference.
Overall, the intervention to promote systematic ICU admission did not reduce 6-month mortality, increased ICU utilization, and increased in-hospital mortality. Due to substantial variability in outcomes among individual patients, thoughtful assessment of the benefits and risks of ICU admission is needed for every elderly patient presenting with critical illness.
Appropriate ICU resource allocation is an important issue for hospital systems. Prior observational studies regarding systematic ICU admission have shown conflicting results regarding its benefits in the elderly. This randomized clinical trial suggests that systematic ICU admission of all critically ill elderly patients may not be warranted, but careful assessment of the benefits and risks of ICU admission for each critically ill elderly patient is warranted.
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