Dr. Urvashi Vaid, MD, MS., Instructor, Division of Pulmonary & Critical Care Medicine at Thomas Jefferson University reviews a recent article in the NEJM, Chen et al examine the hypothesis that patients with a high severity of illness are more likely to be admitted to the ICU when compared to patients with low severity of illness.
In a recent article published in the New England Journal of Medicine. Chen et al examine the hypothesis that patients with a high severity of illness are more likely to be admitted to the ICU when compared to patients with low severity of illness. This retrospective study involved 101,912 patients from 121 VA acute care hospitals. The authors used the comprehensive electronic health records available at the VA for this study. Interestingly, the results supported their hypothesis for the most common non cardiac diagnoses, but not for the common cardiac diagnoses. They concluded that triage decisions involving ICU admission are not based on severity of illness alone but other factors. They hypothesized that severity scores for cardiac diagnoses may not reflect the need for critical care, or that protocols or physician preferences or the need for telemetry may have dictated ICU admission for this set of patients. The authors maintain that the ICU remains a place for the sickest of the sick and using HIT to triage patients is the first step in achieving this. Triage decisions are complex. Several studies have shown that deterioration in vital signs predicts ICU admission and at times mortality. There is little resistance to transferring this subset of patients to the ICU. In addition, mortality has been shown to be higher for patients initially triaged to the floors from the emergency room who subsequently deteriorate and are admitted to the ICU. What if we could predict this future deterioration on admission using clinical information from EHR? Would this mean that the patient would go directly to the ICU? Or would this mean we may be able to intervene and prevent the deterioration and thus the ICU admission? Given the rising costs of and demand for critical care, especially in the elderly and the paucity of trained intensivists, investing in a research tool that could accurately predict the need for an ICU bed as well as condition-specific outcomes would be of great value. In addition, the federal mandate for EHR is increasingly becoming a certainty making possible a widespread digital system that ideally would communicate freely, facilitating research and patient care. We agree that using HIT to help develop a triage tool is the way of the future.
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