Methods
Definition Participants Target population Target audience Key question development and Delphi process Literature search Evidence summary and recommendations Open external consultation Guideline review The consensus statement and grading of the quality of practice guidelines were developed using the Appraisal of Guidelines for Research & Evaluation Instrument (AGREE II). [8] Definitions The te
Key question development and Delphi process
Evidence summary and recommendations
The consensus statement and grading of the quality of practice guidelines were developed using the Appraisal of Guidelines for Research & Evaluation Instrument (AGREE II). [8]
Definitions
The term ‘triage’ is derived from the French word meaning ‘to sort’. Triage, in the context of intensive care medicine (ICM), describes the process of prioritisation of patients for admission when available resources are insufficient to satisfy all needs or requests for admission. Triage has the potential of denying admission to a patient who might benefit from intensive care, in favour of another who is deemed to be of higher priority. [9]
Participants
Participants in the consensus meeting were recruited from the Critical Care Society of Southern Africa (CCSSA) by the chairperson of the CCSSA Congress held in Sun City on 19 - 22 October 2017, and the President of the CCSSA (FP and IJ). The invited participants (Appendix 1) included intensive care specialists and intensive care nurses from public and private healthcare institutions with experience or research record in triage, including those with an interest in bioethics, hospital administrators and a member of the legal profession. An intensivist with clinical experience in triage, and previous involvement in triage research and international consensus processes, was invited to chair the round-table meeting (GJ).
Target population
The consensus recommendations and guideline were developed to inform decision-making for adult patients referred for ICU admission.
Target audience
The target audience was doctors, nurses and other healthcare professionals caring for severely ill patients who may require ICU admission on a day-to-day basis, as well as hospital administrators and governmental bodies with jurisdiction over healthcare matters.
Key question development and Delphi process
The consensus statement recommendations were developed using a Delphi process prior to the face-to-face round-table consensus meeting on 18 October 2017. Key questions related to current principles and practice regarding admission, rationing and triage were drafted by the meeting co-chairs in early April 2017 (GJ and FP). Between April and July 2017, a modified Delphi process, [10] using REDCap (Research Electronic Data Capture), a secure web application hosted at The Chinese University of Hong Kong, was undertaken during which all invited participants progressively modified, deleted or added questions. Questions were retained if approved by 80% or more of participants in the current form.
Questions not receiving 80% approval were modified on the basis of participant suggestions, and subjected to a further round of voting. Failure to secure 80% consensus after modification and 3 rounds of voting resulted in elimination of a question. Once no further questions were proposed, and repeated voting failed to significantly change consensus percentages, 14 key questions were finalised for review and discussion at the face-to-face consensus meeting. To facilitate an appropriate review of the question and provide evidence to support consensus recommendations in response to the key questions, a literature review was conducted.
Literature search
In August 2017, each key question identified by the Delphi process was formulated into a population, intervention, comparison, outcomes (PICO) format, or abstracted to ‘key search terms’ as appropriate by VL, assisted and supervised by GJ and AL. A search of the electronic databases (OVID MEDLINE January 1946 - August 2017) and OVID EMBASE January 1910 - August 2017) was made. The medical subject headings and text words used for the search strategy, developed with help from the Chinese University of Hong Kong (CUHK) medical librarian, included the following: ‘health care rationing’, ‘intensive care units’, ‘patient admission’, ‘patient discharge’, ‘patient selection’, ‘policy making’, ‘practice guidelines’, ‘practice patterns, physicians’, ‘private sector’, ‘public sector’, ‘quality of health care’, ‘refusal to treat’, ‘resource allocation’, ‘resuscitation orders’, ‘south africa’ and ‘triage’. The search yielded a total of 1 917 articles for screening. Where more than 10 articles were identified for a specific question, we exported the results into Covidence systematic review software (Veritas Health Innovation, Melbourne, Australia). The participants were divided into pairs to address the evidence related to specific questions. Each pair was allocated questions broadly matching areas of interest and expertise. Each pair of allocated expert participants constituted a panel and independently screened the articles for their allocated question to establish relevance. Non-relevant articles were eliminated. Where there was disagreement, a consensus decision was reached by direct correspondence or discussion.
Evidence summary and recommendations
Between August and October 2017, the expert panel members summarised available evidence, and formulated draft recommendations arising from each question. These summaries were presented and discussed by all participants during the morning of a full-day face-to-face round-table meeting at Sun City prior to the annual CCSSA scientific meeting on 18 October 2017. The principles of the GRADE approach were used to formulate and report recommendations and levels of evidence. [11,12] After discussion, preliminary consensus was reached on all summaries and recommendations.
Recommendations were classified as strong (grade 1), weak (grade 2) or ungraded, based on an assessment of the quality of available evidence, the balance between desirable and undesirable effects, considerations of competing values and preferences, and an assessment of the outcomes achieved for the magnitude of resource use. [12,13] Grading (A to D) for the quality of evidence supporting a recommendation was given to reflect the certainty of evidence underlying the recommendation (Table 1).
The first draft of the consensus statement was completed after collation of summaries and graded recommendations, and development of the proposed guideline. The consensus statement was circulated by email to all members for comment in April and May 2018. All authors approved the final draft statement by email circulation.
Table 1. Description of the use of strength of recommendation and quality of evidence scores, modified from the GRADE system [12,13]
| Recommendation | Quality of evidence supporting recommendation | Interpretation |
| 1 (Strong) Benefits strongly outweigh burdens and/or costs |
A (High) Future research unlikely to change confidence in current known findings |
Recommendation should be implemented by relevant parties. In a clinical setting, most patients should receive this therapeutic decision. |
| 1 (Strong) Benefits strongly outweigh burdens and/or costs |
B (Moderate) Future research may change confidence in current known findings |
Recommendation should be implemented by relevant parties. In a clinical setting, most patients should receive this therapeutic decision. Recommendations may change with better-quality evidence. |
| 1 (Strong) Benefits strongly outweigh burdens and/or costs |
C (Low) Future research likely to change confidence in current known findings |
Implementation should be considered by relevant parties. In a clinical setting, most patients should receive this therapeutic decision. Recommendations likely to change with better-quality evidence |
| 2 (Weak) Uncertainty over balance of burdens and/or costs |
A (High) Future research unlikely to change confidence in current known findings |
Implementation may be considered by relevant parties. In a clinical setting, decision-making may differ from recommendation depending on individual circumstances. |
| 2 (Weak) Uncertainty over balance of burdens and/or costs |
B (Moderate) Future research may change confidence in current known findings |
Implementation may be considered by relevant parties. In a clinical setting, decision-making may differ from recommendation depending on individual circumstances and future research. |
| 2 (Weak) Uncertainty over balance of burdens and/or costs |
C (Low) Future research likely to change confidence in current known findings |
|
| Ungraded | D (Very low) Insufficient evidence to support a recommendation |
Recommendation based solely on consensus view of participants. Future research is required. |
Open external consultation
The final draft of the consensus recommendations was made openly available on the CCSSA website https://www.criticalcare.org.za/ConICTri/Whatis from August 2018 for 3 months, and CCSSA members (nurses, doctors, allied health and industry) were invited to review and comment on the proposed draft. The site was also open to public view and participation. The consensus statement with relevant open external consultation additions included was circulated to all invited participants in December 2018 for final approval.
Guideline review
A review of the existing recommendations and accompanying guideline should occur 5 years after publication of this document, and be implemented by the guideline development group of CCSSA, unless an earlier revision is mandated by emerging high-quality medical evidence. The updated statement and guideline should, where possible, incorporate findings from an audit of implementation data as described in Table 3.
Table 3. Selected key audit metrics relevant to quality assurance and performance improvement when performing triage
| ICU utilisation and performance metrics | Total number of ICU admissions including a severity of illness score, referral source and referral specialty ICU occupancy (mean daily occupancy rate, number of days with no available beds, etc.) ICU length of stay, unplanned re-admission rates Adjusted/standardised mortality rates |
| Triage | Number of emergency referral patients refused admission or admission delayed Number of elective surgical referral patients refused or delayed Reasons for delayed admission or refusals, including admission priority ranking* Number of critically ill patients transferred in and out of the hospital and reasons for transfer Number of conflicts, e.g. with patient/family members or healthcare professionals |
| Discharge | Number of after-hours discharges Delayed discharge and reasons for delayed discharge (e.g. no beds in ward) |
| Triage policy | Compliance – availability of written policy, availability of designated triage personnel, number of instances of violation of triage policy and nature of violations |
| * Reasons for refusal should allow differentiation between refusal imposed by limited resources (triage) and other reasons such as patients for whom ICU would not be of benefit (alternatively termed futility), e.g. patient is not sufficiently ill to warrant admission, or too severely ill, and highly likely to die even with ICU admission See the clinical practice guideline [7] for a detailed discussion. | |
The Critical Care Society of Southern Africa Consensus Statement on ICU Triage and Rationing (ConICTri)_SAMJ/SAJCC_July 2019, Vol. 35, No. 1