An Explanatory Mixed-methods Study of "ICU net benefit": Triage and Trajectory for Sepsis and Acute Respiratory Failure.

Rationale: Patients with sepsis and/or acute respiratory failure are at high risk for death or long hospital stays, yet limited evidence exists to guide triage to intensive care units (ICUs) or general medical wards for the majority of these patients who do not initially require life support.

Objectives: To identify factors that influence how hospitals triage patients with capacity-sensitive conditions and those factors that may account for observed ICU relative to ward, or ward relative to ICU, benefits for such patients.

Methods: We conducted an explanatory sequential mixed-methods study. As part of a 27-hospital, two-health system retrospective cohort study, we calculated hospital-specific measurements of ICU net benefit for patients with sepsis and/or acute respiratory failure. Hospitals among the highest ICU net benefit and lowest ICU net benefit (or highest ward net benefit) from each study health system were selected for in-depth qualitative study. At each hospital interviews were conducted with emergency department (ED), ward, and ICU clinicians and administrators. Interview transcripts were analyzed using flexible coding and the framework method.

Results: Interviews were conducted with 118 respondents (46 physicians, 43 nurses, 5 advanced practice providers, and 24 administrators) from four hospitals. Respondents across hospitals agreed that the prediction of patient trajectory is central to triage decisions, but there was variation in opinion across work locations about optimal pre-triage ED interventions in terms of intensity, repetition, clinical reassessment, and observation duration. The main difference observed between high and low ICU net benefit hospitals related to the way respondents working in the ICU and ward described their responses to patients who experience rapid clinical deviations from triage-expected trajectories including sustained lack of critical care needs after admission to the ICU and acute critical care needs after admission to the ward. Hospitals with low ICU net benefit (or high ward net benefit) had particularly robust and proactive rapid response and clinical decompensation surveillance practices for ward-admitted patients.

Conclusions: Particularly proactive rapid response programs that deliver on-location critical care may quantitatively increase ward net benefit by bringing ICU benefits without ICU-associated harms to ward patients who become critically ill.