title: Development of an algorithm to aid triage decisions for intensive care unit admission: a clinical vignette and retrospective cohort study.
abstract: BACKGROUND
  Intensive care unit (ICU) admission triage is performed routinely and is often based solely on clinical judgment, which could mask biases. A computerized algorithm to aid ICU triage decisions was developed to classify patients into the Society of Critical Care Medicine's prioritization system. In this study, we sought to evaluate the reliability and validity of this algorithm.
  
  
  METHODS
  Nine senior physicians evaluated forty clinical vignettes based on real patients. The reference standard was defined as the priorities ascribed by two investigators with full access to patients' records. Agreement of algorithm-based priorities with the reference standard and with intuitive priorities provided by the physicians were evaluated. Correlations between algorithm prioritization and physicians' judgment of the appropriateness of ICU admissions in scarcity and nonscarcity settings were also evaluated. Validity was further assessed by retrospectively applying this algorithm to 603 patients with requests for ICU admission for association with clinical outcomes.
  
  
  RESULTS
  Agreement between algorithm-based priorities and the reference standard was substantial, with a median κ of 0.72 (interquartile range [IQR] 0.52-0.77). Algorithm-based priorities demonstrated higher interrater reliability (overall κ 0.61, 95% confidence interval [CI] 0.57-0.65; median percentage agreement 0.64, IQR 0.59-0.70) than physicians' intuitive prioritization (overall κ 0.51, 95% CI 0.47-0.55; median percentage agreement 0.49, IQR 0.44-0.56) (p = 0.001). Algorithm-based priorities were also associated with physicians' judgment of appropriateness of ICU admission (priorities 1, 2, 3, and 4 vignettes would be admitted to the last ICU bed in 83.7%, 61.2%, 45.2%, and 16.8% of the scenarios, respectively; p < 0.001) and with actual ICU admission, palliative care consultation, and hospital mortality in the retrospective cohort.
  
  
  CONCLUSIONS
  This ICU admission triage algorithm demonstrated good reliability and validity. However, more studies are needed to evaluate a difference in benefit of ICU admission justifying the admission of one priority stratum over the others.
authors.affiliation: Medical sciences doctoral program, University of Sao Paulo Medical School, Sao Paulo, Brazil. jgrr25@gmail.com.|Intensive Care Unit, Hospital Sao Rafael, Salvador, Brazil. jgrr25@gmail.com.|UNIME Medical School, Lauro de Freitas, Brazil. jgrr25@gmail.com.
authors.forename: Joao Gabriel Rosa
authors.identifier: http://orcid.org/0000-0003-2201-9872
authors.initials: JG
authors.lastname: Ramos
authors.affiliation: Emergency Department, Hospital das Clinicas, University of Sao Paulo Medical School, Sao Paulo, Brazil.
authors.forename: Beatriz
authors.initials: B
authors.lastname: Perondi
authors.affiliation: Emergency Department, Hospital das Clinicas, University of Sao Paulo Medical School, Sao Paulo, Brazil.
authors.forename: Roger Daglius
authors.initials: RD
authors.lastname: Dias
authors.affiliation: Intensive Care Unit, Hospital Nove de Julho, Sao Paulo, Brazil.
authors.forename: Leandro Costa
authors.initials: LC
authors.lastname: Miranda
authors.affiliation: Bioethics Committee, Hospital das Clinicas, University of Sao Paulo Medical School, Sao Paulo, Brazil.|Discipline of Bioethics, University of Sao Paulo Medical School, Sao Paulo, Brazil.
authors.forename: Claudio
authors.initials: C
authors.lastname: Cohen
authors.affiliation: Pulmonary Division, Heart Institute (InCor), Hospital das Clinicas, University of Sao Paulo Medical School, Sao Paulo, Brazil.
authors.forename: Carlos Roberto Ribeiro
authors.initials: CR
authors.lastname: Carvalho
authors.affiliation: Intensive Care Unit, Emergency Medicine Discipline, Hospital das Clinicas, University of Sao Paulo Medical School, Sao Paulo, Brazil.
authors.forename: Irineu Tadeu
authors.initials: IT
authors.lastname: Velasco
authors.affiliation: Intensive Care Unit, Emergency Medicine Discipline, Hospital das Clinicas, University of Sao Paulo Medical School, Sao Paulo, Brazil.|Palliative Care Team, Hospital Sirio-Libanes, Sao Paulo, Brazil.
authors.forename: Daniel Neves
authors.initials: DN
authors.lastname: Forte
mesh_terms: D000465:Algorithms; D000066491:Clinical Decision-Making / Q000379:methods*; D015331:Cohort Studies; D003422:Critical Care / Q000379:methods*; D016638:Critical Illness / Q000401:mortality / Q000628:therapy; D005260:Female; D006801:Humans; D007362:Intensive Care Units / Q000706:statistics & numerical data*; D008297:Male; D010343:Patient Admission / Q000592:standards; D012189:Retrospective Studies; D016019:Survival Analysis; D016896:Treatment Outcome