Guidelines of the Polish Society of Anaesthesiology and Intensive Therapy defining the rules of qualification and criteria for admitting patients to anaesthesiology and intensive care units

PURPOSE OF THE GUIDELINES

The purpose of the guidelines is to define the conditions for employing physicians specialised in the treatment of adult and paediatric patients to work in anaesthesiology and intensive care units, which act in compliance with the priorities of patient treatment benefits and are compatible with the current medical knowledge. The subject of the guidelines is the patient and his/her welfare when in need of medical assistance, and when any delay in providing it could cause a life threat, severe bodily harm or severe health impairment.

RECIPIENTS OF THE GUIDELINES

The guidelines are intended solely for medical specialists in anaesthesiology and intensive care as well as physicians undergoing specialist training in the field of anaesthesiology and intensive therapy and currently providing health services in anaesthesiology and intensive care units treating adults and children.

INTRODUCTION

The Polish Society of Anaesthesiology and Intensive Therapy appointed the Working Group of experts in the field of anaesthesiology and intensive therapy who were assigned to prepare this document. The key principle of the guidelines was based on the criteria of patient health benefits resulting from application of invasive therapeutic interventions conducted in anaesthesiology and intensive care units, starting with the highest level of patient benefits, followed by situation where benefits are less expected, and down to highly doubtful or a lack of benefits (referred to as ‘priorities’) [1, 2]. Specification of these principles is intended to assist specialists in anaesthesiology and intensive therapy in the qualification of patients who will potentially benefit from receiving intensive therapy in the anaesthesiology and intensive care units or paediatric anaesthesiology and intensive care units in circumstances which require the provision of prompt medical assistance in cases of life-threatening conditions, serious bodily injury or severe health disorders. All such situations demand clear-cut methodological support.

The present guidelines are applicable to management in anaesthesiology and intensive care units or paediatric anaesthesiology and intensive care units.

Qualification for treatment in the anaesthesio logy and intensive care unit is always utilitarian yet consistent with the principle of the greatest chance of survival, recovery and return to society. The purpose of the document is to facilitate risk management in compliance with the risk management doctrine.

Due to limited access to reliable, evidence-based data, the guidelines are a result of the consensus of the Working Group. Additionally, the most common clinical conditions and situations that could qualify a patient for, or disqualify a patient from, treatment in the intensive care unit have been verified by the appointed Group of experts. The members of the Board of the Polish Society of Anaesthesiology and Intensive Therapy, the chairman or delegated members of sections and branches of the Polish Society of Anaesthesiology and Intensive Therapy, and regional consultants in the field of anaesthesiology and intensive therapy were invited to express their opinions. each of the experts assessed the correctness of decisions in individual clinical scenarios on a scale of 0–100, where 0 meant “I completely disagree with admitting the patient to the anaesthesiology and intensive care unit or paediatric anaesthesiology and intensive care unit”, and 100 meant “I completely agree with admitting the patient to the anaesthesiology and intensive care unit or paediatric anaesthesiology and intensive care unit”. The score to each answer was averaged. The analysis was the experts’ subjective assessment, and therefore it should only play an additional, advisory role in making clinical decisions.

DISCUSSION OF RECOMMENDATIONS

The task of intensive therapy is the application of advanced, highly specialized therapeutic methods and techniques by highly qualified medical personnel to save lives and restore or improve the health of the most seriously ill patients. When taking qualification-related decisions, the following should be considered: directness and degree of threat to life and health (i.e., failure or dysfunction, degree of severity or progression and organ damage), reversibility of the disease process, comorbidities, and the results of accessory examinations (imaging, laboratory tests, etc.) The results of accessory examinations cannot be an independent criterion; they should be regarded as one of the ways of assessing whether the previously indicated general medical criteria have been met. The main aims of accessory examinations are to determine more conclusively the patient’s condition and to establish an appropriate prognosis. The patient’s chronological age should not be a criterion; instead, his/her biological and functional status as well as the degree of impairment, disability or frailty should be taken into account. It is not recommended to qualify patients for admission to the anaesthesiology and intensive care unit solely on the basis of numerical data or prognostic scoring scales which are only of advisory nature. The recommended scales include APACHe II, SAPS II and SOFA for adults, and PIM, PRISM and PelOD for children. The activities of emergency response teams, for instance, may also be helpful in observing the trend of changes in those individuals who may require hospitalization in the anaesthesiology and intensive care unit. In order to establish a full clinical picture of a patient’s condition, all the obtained information should be put together and analysed as a whole. A patient with a life-threatening condition is a priority before a patient with a health-threatening condition. However, the degree of threat in each of them should also be considered. Therefore, if a patient with a life-threatening condition is not in direct danger of death and his/her condition does not require immediate interventions, while a patient with a health-threatening condition needs immediate medical assistance, the latter should unusually be admitted to the anaesthesiology and care therapy unit first. The procedures should consider the hospital environment, equipment and working conditions of the personnel, with possible rotation between the existing schemes (rotation of departments, staff, work of treatment teams, the order of admissions and procedures performed, or their temporary suspension). It should be made sure that the hospital care team members in the anaesthesiology and intensive care unit are provided with medical supplies, drugs, personal protective equipment and medical equipment, in accordance with the specified organizational standards of health care that are to be applied if serious damage to a patient’s health is likely to occur in the near future. Under such circumstances, an individual in a state of health emergency should be attended to first. If life-threatening conditions of patients are comparable, rescue activities should be carried out first in the patient whose chances of survival are higher.

If a patient expressed a legally confirmed decision to refuse treatment in the anaesthesiology and intensive care unit, it should not be questioned or undermined. each patient should be treated individually, and it should be made sure that the patient agreed or refused to undergo intensive therapy procedures (the steps should preferably be taken in advance). Before giving consent or refusing the treatment, the patient should be thoroughly informed about the consequences of his/her decision regarding life and health. Subsequently, if the patient maintains his/her decision, the decision is binding for the physician. It is important to make a record of the fact that detailed information has been provided and to obtain the patient’s statement in writing or, if that is not possible, it may be an oral statement in the presence of at least two impartial witnesses who confirm the patient’s decision in writing. The above considerations do not apply to unconscious patients. A person known to the patient may be a source of information about the patient’s previously expressed decision. How ever, only the statement of a cognizant patient himself/ herself is binding. Nevertheless, respecting the patient’s decision does not mean that the patient (and much less people from the patient’s environment) can force the physician to use intensive therapy methods and procedures that would be against currently applicable medical standards of treatment (current medical knowledge).

It is unacceptable to enforce a decision on admission to the anaesthesiology and intensive care unit based on grounds other than medical. Any medical specialist is allowed to refer a patient to intensive care treatment in the anaesthesiology and intensive care unit if, according to the doctor’s assessment and current medical knowledge, the patient will benefit from the treatment in the anaesthesiology and intensive care unit. Justification of the doctor’s decision about the patient’s hospitalization in the anaesthesiology and intensive care unit is verified by an anaesthesiology and intensive care specialist. It is obligatory that a qualification form for treatment in the anaesthesiology and intensive care unit is routinely used (Annex 1A – for adults, Annex 1B – for children), and this form should be included in the patient’s medical history (in the original version or as a copy for the admitted patients) or in the medical report book (in the original version or as a copy for non-admitted individuals). It is medically justified to admit adult or paediatric patients defined as Priorities 1 and 2 to the anaesthesiology and intensive care unit. Patients identified as eligible for intensive therapy treatment should be promptly admitted to the anaesthesiology and intensive care unit. If it is impossible to admit a patient to the nearest anaesthesiology and intensive care unit, the physician referring the patient should contact the Crisis Management Centre to secure a place for the patient in another intensive care unit nearby. Then, the doctor`s obligation is to make sure that the patient’s hospitalization in that other intensive care unit is consistent with the aforementioned principles.

Admitting patients classified as Priority group 4 is generally unjustified. Admitting a Priority 4 patient should always be agreed upon with the physician in charge of the anaesthesiology and intensive care unit, and such information must be included in the patient’s medical history. In medically doubtful situations (e.g. individuals from Priority group 3), it is reasonable to call a medical case conference [6] and assess the patient’s prognosis according to the current medical prerogatives; the likelihood of the patient’s condition’s being reversible should also be assessed. The assessment is based on the knowledge and experience of the conference participants. This assembly of consultants is also a good opportunity to assess potential benefits for the patient from implementation of the therapeutic methods (especially invasive) as well as human resources available in the anaesthesiology and intensive care unit. It is particularly important in the case of patients who are “too healthy” to benefit from treatment in the anaesthesiology and intensive care unit as well as in those patients who are “too sick” to benefit from such treatment, including those suffering from incurable neoplastic disease, end-stage chronic organ disease, patients after extensive surgery with postoperative complications and those with numerous co-morbidities that significantly affect the degree of disability and quality of life. evidence that futile therapy has been initiated should be a strong prerogative to disqualify a patient from treatment in the anaesthesiology and intensive care unit. For a terminally ill patient, futile therapy means unnecessary suffering, pain, fear and loss of dignity in the face of death. Intensive therapy treatment must not be confused with intensive medical care and palliative care or hospice care. In terminal patients, the physician is not obligated to undertake and conduct futile therapy and apply emergency procedures, including resuscitation. Prolonging the dying process, combined with applying invasive procedures causing suffering for the patient, may be a violation of the patient’s dignity. Therefore, the physician has to assess whether such actions are justified, or whether they are in conflict with the subjective treatment of the patient and respect for his/her right to a dignified death.

When determining the criteria for discharging an adult or paediatric patient from the anaesthesiology and intensive care unit, the same factors (priorities) should be taken into account that are assessed when determining their admission criteria. The patient should be discharged from the anaesthesiology and intensive care unit to another ward, care and treatment facility, nursing and care facility, or other therapeutic centres, or sent home immediately after their general condition has stabilized and the clinical criteria that do not qualify them for further treatment in an anaesthesiology and intensive care unit have been met (i.e. the patient is no longer in Priority group 1, 2 or 3); the patient should receive written and oral prescriptions and recommendations. Patients who will not benefit from treatment in the anaesthesiology and intensive care unit and whose intensive therapy should not be continued due to the irreversibility of the disease process (i.e. Priority 4) should be discharged from hospital and receive palliative, hospice or another type of care to let them die with dignity.

The policy of planning the availability of intensive care units/stations to cover the current needs should be implemented responsibly and the methods of transferring patients between intensive therapy units should be formulated. This task rests with the health care organizer in the entity performing medical activities. From an intensive therapy management perspective, the relationship between the demand for intensive therapy and its supply is the most important aspect of this overall health situation. When the level of resources is sufficient to meet the demand, proper management of intensive therapy consists only in rationing it according to the norms of its practical rationality (i.e. not applying intensive therapy when it is ineffective or unnecessary). When the level of resources is insufficient, ordinary (i.e. when the resources are relatively insufficient) or extraordinary (i.e. when there is an overall shortage of resources), rationing is necessary. In this context, continuing treatment that will no longer be beneficial for the patient (i.e. will not improve the prognosis) is unjustified, and it removes the opportunity for prompt implementation of effective intensive therapy in patients who are in a real life-threatening or health-threatening condition. Decisions about readmission of the patient to the anaesthesiology and intensive care unit are complex and should be made by a team, conciliarly, as in the case of Priority 3 patients.

The medical criteria for admitting adult or paediatric patients for treatment in the anaesthesiology and intensive care unit in the case of catastrophes, mass accidents, natural disasters, epidemics and other emergency situations which will pose a threat to human life or health on a large scale may only exceptionally diverge from the principles described in this document and under such circumstances the criteria should always be consistent with the consensus statement of the Polish Society of Anaesthesiology and Intensive Therapy, independently of this document. The statement should contain medical indications for admitting patients to the anaesthesio logy and intensive care unit and describe the algorithm of each medical procedure, thereby ensuring synchronized cooperation of the medical and non-medical personnel, including the hospital administrative personnel, when prompt, targeted actions need to be taken. First of all, in such circumstances, a transparent, fit-for-ability and fair process of qualifying for treatment, regardless of age, sex, religion, origin, etc., should be ensured.

The procedure of such intensive care triage has been described previously [3]. It is impossible to produce uniform recommendations for all emergency situations, and this issue is beyond the scope of the present document.

As of the date of publication of this document, the “Guidelines of the Polish Society of Anaesthesiology and Intensive Therapy defining the rules of qualification and criteria for admitting patients to anaesthesiology and intensive care units – February 2012”, of February 22, 2012, shall become invalid.