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| Journal of the New Zealand Medical Association,
11-June-2010, Vol 123 No 1316
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The demand for health care increasingly exceeds available
resources and the pressure to contain the cost of medical care in the face of an
ageing population is leading to growing pressure to use available resources as
efficiently as possible.1
In the intensive care setting, resource conservation
requires careful determination of who receives treatment based on expected
benefit. Intensive care triage requires a determination of which patients are
‘too well’ to require intensive
care2 as well as which patients are ‘too
sick’ to benefit.3 Considerations of
individual patient’s wishes and quality of life are also
important.4,5
Triage decisions are difficult because even the best
available prediction scores are unable to predict survival with sufficient
accuracy to guide decisions about individual patients and factors such as lead
time bias and casemix may further confound their
interpretation.6
Although studies investigating the process of intensive care
triage have previously been performed in the United
Kingdom,7
Europe,8,9 and the United
States,10 no such study has previously been
conducted in Australia or New Zealand. Previous studies have demonstrated that
there are significant differences in both the manner and frequency with which
intensive care treatment is withheld in different parts of the world and in
different cultures.11
Although New Zealand and Australia are often considered
culturally similar, there are significant differences in our respective cultural
heritages. For example, New Zealand has larger proportions than Australia of
indigenous people (15% vs 2.5%) and Polynesians (7% vs
0.5%).12–14 In addition, there are a
number of factors in Australia such as greater availability of private intensive
care, a higher level of funding for medical care and, a larger number of
intensive care beds that are likely to lead to differences in intensive care
triage practice.
We hypothesised that there would be differences between
Australia and New Zealand in the attitudes towards and practice of intensive
care triage and sought to demonstrate these differences by way of a survey.
MethodsThis study involved an online survey of intensive care
specialists and trainees in Australia and New Zealand. The sample of 731
intensive care specialists and trainees were identified by a combination of an
internet search of State (and New Zealand) Medical Registers, and a search of
intensive care unit websites, supplemented by direct phone contact with
individual intensive care units.
The survey was designed to examine views about a range
of triage scenarios and also to review recent triage practice. Prior to
distribution, the survey was piloted on a small number of intensive care
specialists and some minor modifications to the survey were made as a result of
this.
The intensive care specialists and trainees in the
sample were invited to participate in the survey by an email sent on 19/05/09
that contained a link to an online survey on the website www.surveymonkey.com. A subsequent
reminder was sent on 27/05/09 in order to maximise the response rate. The survey
was closed to responses on 04/06/09. The survey was approved by the Multi-Region
Ethics Committee of the Health Research Council of New Zealand
(MEC/09/25/EXP).
Respondents were required to answer a number of
demographic questions including location of practice, qualifications and
experience. Those respondents who made final decisions about whether or not to
admit a patient were asked about recent triage decisions including the number of
such decisions they had made in the previous week and how the decisions were
made and communicated. All respondents were asked to consider specific triage
scenarios.
For each scenario they were asked to consider (a) how
appropriate (on a 5-point Likert scale) they felt that intensive care was and
(b) whether they would admit the patient on the basis of the information
provided.
The results were analysed using the R statistical
package.15 Independent samples t-tests, with
two-sided p-values, were used to compare means between New Zealand and
Australia. Chi-squared tests were used to compare the proportions over
categories, including the distribution over the 5-point Likert scale responses.
Where 20% or more of the expected counts in a contingency table were less than 5
so that the standard Chi-squared test is invalid, a Monte Carlo simulation
method was used to compute p-values.16, 17 In
addition to Chi-square tests of association, logistic regressions were carried
out to test for the importance of the explanatory variables: ‘is a
trainee’ (yes/no) and ‘has an additional qualification’
(yes/no).
ResultsRespondents—A total of 238 responses
to the survey were obtained, representing a response rate of 33%. The proportion
of respondents from various geographical locations was similar to that of all
trainees and specialists registered with the Joint Faculty of Intensive Care
Medicine except that the proportion of total respondents from New Zealand was
higher and the proportion from New South Wales lower, than the proportion of
trainees and specialists from New Zealand. The demographics of respondents are
shown in Table 1.
Table 1. Demographics of
respondents
* Two respondents did not answer this question.
Recent triage decisions—Of those
surveyed, 134 personally made decisions about whether to admit patients to the
intensive care unit of which 77% were consultants and the remainder were
trainees. These 134 were asked about triage decisions they had made in the
previous week. The mean number of decisions about whether to admit a patient to
the intensive care unit in New Zealand was 6.3 (95% CI 4.6–8.0) and 8.5 in
Australia (95%CI 6.6–10.4) (test for difference in means, p=0.08). The
mean refusal rate for the week prior to the survey was 31% (95%CI 20–42)
among New Zealand respondents and 25% (95% CI 20–30) among Australian
respondents (test for difference in proportions, p=0.35).
79 respondents had refused an admission in the previous
week. The sources of views sought in coming to this decision are shown in Figure
1 and the means of communicating decisions to refuse admission are shown in
Figure 2.
  No differences between Australia and New Zealand were found
in the distribution of levels of experience or proportions having non-intensive
care unit specialist qualifications. 41% of patients who were declined admission
to intensive care were physically reviewed by an intensive care
specialist.
Intensive care triage scenarios—For
all 7 triage scenarios described, (see Table 2) two comparisons were made
between New Zealand and Australia. The first comparison was with respect to
whether the respondents agreed that admission was appropriate, and the second
was whether the respondents would actually admit the patient (the results are in
Table 3).
We also test for associations with being a trainee, and with
having an additional qualification. No associations were found with respect to
having additional qualifications, but in two scenarios trainees responded
differently to specialists. In most of the scenarios there was a wide variety of
opinions, in several cases spanning the full range of the 5-point Likert scale
used to measure the strength of agreement that the patient should be admitted.
Table 2. Triage scenarios
The responses for all triage scenarios were similar for all
States in Australia; however, the responses from New Zealand were often
significantly different from those from Australia. The most striking difference
was in Scenario 1, involving a previously well 50-year-old woman with an
intracerebral haemorrhage that the neurologist described as 'non-survivable' and
who it was felt may progress to brain death over the next 48 hours (see Figure
3).
Table 3. Results of Chi-squared tests for
differences between New Zealand and Australia
[All tests are Chi-squared tests of association.
*=significant at the 5% level]
Figure 3. Scenario 1: Comparison of responses
to the question: ‘Do you agree that Intensive Care Admission would be
appropriate for a previously well 50-year-old woman with an intracerebral
haemorrhage that the neurologist describes as non-survivable and who you feel
may progress to brain death over the next 48 hours?’ and whether
respondents would admit this patient
Australian respondents were more positive about the
appropriateness of admission in this scenario than their New Zealand
counterparts (p=0.0001) and a greater proportion of Australian respondents would
have admitted in this scenario (p=0.0002).
Scenario 2, which described a 30-year-old female with
relapsed acute myeloid leukaemia following a bone marrow transplant who had
acute respiratory distress syndrome and imminently required intubation, again
demonstrated significant differences between Australia and New Zealand with
respect to views on appropriateness (p=0.0005) and whether or not the patient
should be admitted (p=0.03) (see Figure 4). For this Scenario, trainees were
more likely than specialists to agree that admission was appropriate (p=0.0002)
and more likely to say that they would admit (p=0.0023).
Figure 4. Scenario 2: Comparison of responses
to the question: ‘do you agree that Intensive Care Admission is
appropriate for a 30-year-old female with relapsed acute myeloid leukaemia
following a bone marrow transplant who has ARDS and who you believe will
imminently require intubation?’ and whether respondents would admit this
patient
Scenarios 3 and 4 described a young patient who had been in
a persistent vegetative state for five years and had pneumonia (see Figures 5
and 6). The two scenarios were the same except that in the second scenario the
pneumonia was the event of an iatrogenic complication. In Scenario 3, there were
no differences between the New Zealand and Australian respondents (p=0.58): both
groups in general opposing admission. However, when iatrogenesis was the cause
of the pneumonia a pronounced difference appeared.
While New Zealand respondents generally remained strongly
opposed to intensive care admission, Australian respondents were significantly
less so (p=0.034); more than 20% of Australian respondents would have admitted
the patient compared to 2% (just one respondent) from New Zealand (p=0.0011). In
the latter Scenario, trainees were both more likely to feel that admission was
appropriate (p=0.0035), and more likely to say that they would admit the patient
(p=0.0071).
Scenario 5 described a patient with an infective
exacerbation of COPD on a background of functional impairment. There was no
significant difference between New Zealand and Australian respondents in the
proportions agreeing that the patients should be admitted (p=0.060). However, a
significantly higher proportion of Australian respondents stated that they would
in fact admit the patient (p=0.0004). In both groups the proportion that felt
there was insufficient information to make a decision was high (see Figure
7).
Figure 5. Scenario 3: Responses to the
question: ‘Do you agree that Intensive Care admission would be appropriate
for a 30 year old male with pneumonia requiring ventilation who has been in a
nursing home in a persistent vegetative state for the past 5 years following a
severe traumatic brain injury?’ and whether respondents would admit this
patient
There was broad consensus about Scenarios 6 and 7. Scenario
6 described a 95 year old man with no previous medical history who the
anaesthetist, despite appropriate attempts, had been unable to extubate due to
drowsiness and hypoventilation following an elective laparoscopic hernia repair
(see Figure 8). The overwhelming majority of respondents felt that intensive
care admission was appropriate in the scenario described.
Figure 6. Scenario 4: Responses to the
question: ‘Do you agree that Intensive Care admission would be appropriate
if the patient in a persistent vegetative state described in the previous
question had developed aspiration pneumonia due to malposition of a feeding tube
in the right main bronchus?’ and whether respondents would admit this
patient
No difference was noted between Australia and New Zealand
(p=0.31). The proportion who would have admitted the patient was also the same
(p=1.00). Scenario 7 involved an elderly patient with a massive stroke who was
intubated in a crowded emergency department but for whom extubation and
palliation was planned (see Figure 9). Although some in both countries felt that
admission might be appropriate, the majority were opposed to admission and there
was no significant difference between the two countries in the proportions who
thought that the patient should be admitted (p=0.62) or said they would admit
(p=1.00).
Figure 7. Scenario 5: Responses to the
question: ‘Do you agree that Intensive Care admission is appropriate for a
70 year old male with an infective exacerbation of COPD who has a documented
FEV1 of 0.9L and has failed to improve despite non-invasive ventilation for six
hours in the emergency department? He lives at home but requires help with
showering, shopping and meals.’ and whether respondents would admit this
patient
Figure 8. Scenario 6: Responses to the
question: ‘Do you agree that ICU admission would be appropriate for a 95
year old man with no previous medical history who the anaesthetist, despite
appropriate attempts, has been unable to extubate due to drowsiness and
hypoventilation following an elective laparoscopic hernia repair.’ and
whether respondents would admit this patient
Figure 9. Scenario 7: Responses to the
question: ‘Do you agree that Intensive Care admission is appropriate for
an elderly patient with a massive stroke who has been intubated in a crowded
Emergency Department but is now to be extubated and palliated?’ and
whether respondents would admit this patient
DiscussionThis study was designed to compare Australian and New
Zealand intensive care practitioners with respect to the practice of and
attitudes towards intensive care triage. We have demonstrated that the views of
New Zealand practitioners, with respect to the appropriateness of intensive care
in a range of triage situations, are more restrictive than those of their
Australian colleagues.
Despite these different viewpoints, we did not demonstrate
differences in the rates of refusal of patients referred to intensive care or in
the manner the triage decisions were undertaken or communicated. One explanation
for this apparent discrepancy in these findings is that, despite stating
different views, Australian and New Zealand practitioners actually act in much
the same way. However, a more likely explanation is that patterns of referral
change depending on the previous experience of those making the referral. For
example, if an intensive care unit does not offer admission to a patient with an
infective exacerbation of chronic obstructive pulmonary disease who has mild
functional impairment, the person referring the patient may be less inclined to
make subsequent referrals in similar situations.
There are a number of potential reasons why New Zealand
intensive care units may have more selective admission criteria. Resource
constraint was specifically mentioned by a number of New Zealand respondents as
a reason why they would not admit a patient in a particular scenario, but was
not mentioned by Australian respondents.
New Zealand has fewer intensive care beds (70 per million)
than Australia (88 per million) and both the government and total health care
expenditure in New Zealand is substantially lower than it is in Australia. The
2006 per capita total expenditure on health care in Australia was $3316 (US)
while the New Zealand expenditure was $2420 (US) (September 2009 exchange
rate).18
Cultural differences are well established as reasons that
influence triage decisions11 and cultural
differences between Australia and New Zealand may have an effect. The ICU
‘culture’ or ‘usual practice’ that follows an intensive
care admission may influence triage decisions. If ICU admission is likely to be
followed by continued or escalating levels of therapy in the face of ongoing
deterioration because of the views of family members or other involved
specialists, then intensive care specialists may seek to avoid these situations
by declining admission in the first place. Whereas, if all those concerned are
comfortable with admitting the patient on the proviso that treatment will be
withdrawn if the patient does not respond to early treatment, then admission may
be more likely to occur.
Intensive care doctors and hospitals in New Zealand are
protected from litigation by the Injury Prevention, Rehabilitation, and
Compensation Act19 (that provides an
alternative no-fault compensation scheme) and this may have had some influence
on responses. In the scenario that involved an iatrogenic complication, the
potential for future litigation was mentioned by a number of Australian
practitioners as being influential in their decision to admit the patient.
Given the recent emphasis on increasing organ donation
rates, Scenario 1 (Figure 3) which described a patient with severe brain injury
who may progress to brain death is worthy of further consideration. Those who
disagreed with admitting the patient in this situation often stated that the
intensive care management was not in the patient’s best interest.
An alternative viewpoint, which was also expressed by some,
is that helping to fulfil a patient’s wish to be an organ donor in the
event of non-survivable illness does, in fact, serve that patient’s
interest. The relatively low proportion of practitioners in New Zealand who
would admit a patient with a non-survivable brain injury who may progress to
brain death indicates that there are either significant barriers to admitting
patients in this scenario in New Zealand, or a difference in prevailing opinion
about the appropriateness of this practice. Despite this, organ donation rates
between Australia and New Zealand are similar20
and, as the scenario described is likely to be a relatively rare one, it
probably makes little difference to the overall rates of donation.
Of course, there may be other reasons why practitioners
choose to admit the patient other than those related to organ donation and these
may vary between Australia and New Zealand. These include allowing the family
more time to come to terms with the situation, allowing a further period of
medical assessment and providing end of life care in a more appropriate
environment than a busy emergency department.
We demonstrated a difference between trainees and
specialists for two scenarios. In both cases, trainees were more likely to
admit. Both scenarios described situations in which a poor outcome was likely.
For the situation of acute respiratory distress syndrome requiring ventilation
in the setting of relapsed acute myeloid leukaemia, the tendency of trainees to
admit may be a reflection of a lack of prior experience dealing with this
specific scenario. For the scenario that described an iatrogenic complication,
the tendency to admit may reflect generally more defensive practice amongst
trainees than specialists.
There are a number of weaknesses of the current study
design. Firstly, the 33% response rate, typical of this mode of surveying, means
that it is possible that those who replied to this survey were more interested
in the issue of intensive care triage than those who did not and that the
responses are therefore not representative of Australasian intensive care
practitioners as a whole. It is not possible to estimate the effect of such
self-selection. However, if it operated similarly in both Australia and New
Zealand, this study still compares like with like. Secondly, the questions
regarding recent triage decisions asked respondents to recall recent referrals
and are therefore subject to recall bias. As only 79 respondents had refused a
patient in the previous week, the questions about the process of refusal were
limited to this relatively small sample. Thirdly, the triage scenarios generally
provided only a small amount of detail and it may be that more consistent
responses between respondents would have been obtained if there were more
details available on which to base the decisions.
Nevertheless, the primary purpose of the study was to test
the hypothesis that attitudes towards triage decisions differed significantly
between Australia and New Zealand and the differences for many scenarios turned
out to be pronounced. We felt that a balance needed to be struck between
providing sufficient detail to provide the flavour of the scenario described
without decreasing the likelihood of having a respondent complete the survey by
making scenarios unduly complex. We decided that a larger number of less complex
scenarios was more desirable than a smaller number of more complicated ones in
order that a broader range of situations could be covered.
Conclusions
This study has demonstrated that there are significant
differences between the views of intensive care practitioners in Australia and
those in New Zealand with respect to a range of common intensive care triage
scenarios with those in New Zealand tending to be more selective in their
admission criteria.
Despite these differences, we did not demonstrate any
difference in the proportion of referrals to the intensive care unit that were
refused. This may be because the more selective criteria used by intensive care
practitioners in New Zealand influence the extent to which referrals are made to
them at all.
Competing interests: None known.
Author information: Paul J Young, Intensive
Care Registrar, Intensive Care Unit, Wellington Hospital, Wellington; Richard
Arnold, Senior Lecturer, School of Mathematics, Statistics and Operations
Research, Victoria University of Wellington, Wellington
Correspondence: Paul Young, Intensive Care
Unit, Wellington Hospital, Private Bag 7902, Wellington South, New Zealand.
Fax: +64 (0)4 3855856; email: paul.young@ccdhb.org.nz
References:
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