ICU Admission and Triage For Fellows and Residents

General Principles:
Appropriate utilization of Critical Care beds is one of the most important things that you will learn as a
Medicine Resident. The 2 guiding principles of whether or not a patient should come to the unit is
severity of illness and intensity of service. The ICU should ideally be used for patients that are critically
ill, who have a reasonable expectation for recovery. However, sometimes patients outside of those criteria
need to be admitted to the ICU because of their need for intense services from nursing, respiratory, etc.
Prioritization model (adapted from the 2016 SCCM Guidelines for ICU Admission, Discharge and
Triage1)

Priority 1:
These are critically ill, unstable patients in need of intensive treatment and monitoring that cannot be
provided outside of the ICU. Usually, these treatments include ventilator support, continuous vasoactive
drug infusions, etc. Priority 1 patients generally have no limits placed on the extent of therapy they are to
receive. Examples of these patients may include post-operative or acute respiratory failure patients
requiring mechanical ventilatory support and shock or hemodynamically unstable patients receiving
invasive monitoring and/or vasoactive drugs.
Priority 2:
These patients require intensive monitoring and may potentially need immediate intervention. No
therapeutic limits are generally stipulated for these patients. Examples include patients with chronic
comorbid conditions who develop acute severe medical or surgical illness.

Priority 3:
These unstable patients are critically ill but have a reduced likelihood of recovery because of underlying
disease or nature of their acute illness. Priority 3 patients may receive intensive treatment to relieve acute
illness but limits on therapeutic efforts may be set such as no intubation or cardiopulmonary resuscitation.
Examples include patients with metastatic malignancy complicated by infection, cardiac tamponade, or
airway obstruction.

Priority 4:
These are patients who are generally not appropriate for ICU admission. Admission of these patients
should be on an individual basis, under unusual circumstances and at the discretion of the ICU Attending.
These patients can be placed in the following categories:
A. Little or no anticipated benefit from ICU care based on low risk of active intervention that could
not safely be administered in a non-ICU setting (too well to benefit from ICU care). Examples
include patients with peripheral vascular surgery, mild diabetic ketoacidosis, mild congestive
heart failure, conscious drug overdose, etc.
B. Patients with terminal and irreversible illness facing imminent death (too sick to benefit from ICU
care). For example: severe irreversible brain damage, irreversible multi-organ system failure,
metastatic cancer unresponsive to chemotherapy and/or radiation therapy (unless the patient is on
a specific treatment protocol), patients with decision-making capacity who decline intensive care

1
ICU Admission, Discharge, and Triage Guidelines: A Framework to Enhance Clinical Operations, Development of
Institutional Policies, and Further Research. August 2016 • Volume 44 • Number 8
 and/or invasive monitoring and who receive comfort care only, brain dead non-organ donors,
patients in a persistent vegetative state, patients who are permanently unconscious, etc.

At times, patients who are classified as priority 3 or 4 may require ICU admission. This may include
patients with DKA requiring an insulin drip and hourly fingersticks and patients with severe brain injury,
potentially brain-dead, who remain on mechanical ventilation.

Details on Gold & Blue MICU Resident Consult Team

- Blue team resident carries the beeper from 7 – 4, except while rounding on their service – rounds
will start between ~7:30 and 9. The individual attending will let you know about when to expect
rounds
Blue Team:
- Carries 2-4 patients and rounds with Blue (pulm consult) attending on those patients
- Admits to Gold service, if involved in the triage, if the admission comes up before ~ 2 PM
- Blue Team: Admissions to Blue service, even when not on a long call day, if the admission
comes before 3
- Blue Team: admissions to the Gold service when on long call after 4 PM
- Gold Team: all admissions that are critically ill and anticipated to be on Gold Service that come
up after 1 PM.
- If one team is very busy — sick Gold team patients, or multiple Blue consults — the Blue and
Gold seniors should work together to divide the work in a way that makes sure the patients
get optimal care — ask for help if necessary!
- All questions on the Blue patients that were rounded on by the pulm attending should go to the
pulm attending until 5 PM
- All MICU consults go to the Gold team attending or MICU fellow
- Blue Team should join Gold team rounds as time permits.
How to do a Critical Care consult:
1. Get the name, MRN, location, reason that the person thinks that they should be admitted
to the MICU, and contact info (if necessary) of the caller. Don’t spend too much time getting
background information.
2. If the patient is on the floor – go see them first, then look in the computer. If the patient is
in the ED, or another ICU, you may look at the basic labs, and background info, but don’t take
too long.
3. Look at the patient and their vital signs, FiO2 requirements, vents settings, pressor
requirements, etc. If the patient is unmonitored, get the most recent BP, check the pulse oximetry,
HR and RR – if the patient “looks bad” and is on the floor, and the MICU fellow or attending
(Gold) isn’t with you, make sure that they are on their way, and they know that you are worried
about the patient. If the patient needs immediate help, have the nurse call an ERT (or Code Blue)
 Alarming Signs/Symptoms
SBP < 100
RR > 22 or < 10
HR >100
Newly Altered mental status
Of these, tachypnea can be quite subtle, but is frequently an early marker for deterioration. 2

4. Do a quick chart review, if appropriate

(if the patient is clearly ill and on the floor, and you believe that the patient needs to come to the
MICU, help stabilize that patient, and have the MICU fellow or attending join you)
5. After you have seen that patient – write a brief note in the chart, and try to let the primary
team know that you will get back to them shortly verbally: “Patient seen and evaluated by MICU
resident. Full note and triage decision to follow. Page 973 203 0003 with any questions”
6. Come up with a preliminary assessment and plan — nothing fancy, and present that to
attending/fellow
7. Present the patient to the MICU Fellow or Attending for a triage decision. If they are
going to be admitted to the MICU, you can do a quick note outlining the plan. If they are going to
be deferred, a full consult note is necessary.
8. If the patient is to be admitted, place the admit order, only after told to by the Fellow or
attending.

These are additional things that we would like to know depending on the situation:
Lactate, how much fluids given, which antibiotics given, prior ICu admissions, if the patient has a
designated HCP and if they have advanced directives.
ED Consults
- See the patient within 30 minutes.
- Even if the patient is a clear admission – intubated, on pressors, s/p TPA, etc, we need basic labs
and a small work-up to be done prior to admission
- Do not place an admit order prior to discussing with Gold Attending

Floor Consults
- See the patient ASAP, to determine stability
- Take the fellow with you, or if the fellow is busy, let them know that you are going to see a
patient on the floor, and to meet you there ASAP
- Don’t be afraid to call for help

Consults from other units/PACU for transfer or admission to the MICU

2
Farley H, Zubrow MT, Gies J, et al: Emergency department tachypnea predicts transfer to a higher level of care in
the first 24 hours after ED admission. Acad Emerg Med 2010; 17:718–722
 - Determine if the patient needs immediate help – ie profound hypoxemia, or if he or she can wait a
bit for us to see him or her, and triage your work appropriately

Consults for transfer from OSH

- The fellow may ask you to make this call. Get the full info – there is a request for transfer sheet,
and present to the attending.

Things to keep in mind

- You are learning how to do this -- you are learning the balance between not knowing enough
background information to be useful to vs knowing a lot, but the patient has decompensated
because you spent too much time on the computer
- If you get 2 consults or more at once, ask for help triaging and prioritizing – have the fellow help
you, dividing and conquering wins the day in the ICU
- When people are calling an ICU consult, they are asking for help.