Critical illness and intensive care I
Criteria for ICU admission
and severity of illness
scoring
Claire Williams
Daniel Wheeler
Abstract
In the UK critical care is a limited resource so must be targeted to those
patients who are most likely to benefit. Timely recognition and treatment
of the critically ill patient may avoid the need for critical care admis-
sion and improve outcome. There is no comprehensive guide to when
patients need critical care admission. The support of single-organ failure
can generally be managed in high-dependency care, whereas respiratory
failure or more than two-organ failure requires ICU admission. Track and
trigger systems and critical care outreach teams have been introduced
following Department of Health advice to identify sick ward patients and
ensure they are treated in a timely fashion to avert deterioration into
organ failure. So far there is no conclusive evidence that they achieve
these aims. Several severity of illness scores are used in critical care
medicine, which have been developed to compare the performance of
different units, and as a research and audit tool. Such tools predict
outcomes of populations of critically ill patients rather than individuals.
Choosing which patient to admit still therefore relies on clinicians’ judge-
ment in addition to assessment of acute physiological derangement and
chronic health status.
Keywords APACHE; critical care; early warning scores; ICNARC; intensive
care; outreach; scoring systems
Criteria for admission
Levels of care
Critical care is a limited resource; the UK Department of Health
critical care bed count in July 2008 found there were 3498 criti-
cal care beds, 1970 in ICUs and 1528 in high-dependency units
(HDUs). This equates to 8.6 critical care beds per 100,000 head
of population whereas the USA has 30.5. The UK Department of
Health published ‘Comprehensive critical care: a review of adult
critical care services’ in 2000 in response to this growing aware-
ness of the lack of critical care beds.1 Levels of care were stated
in this report; level 2 care is usually delivered in HDUs and level
3 care in ICUs (Table 1).
Claire Williams MA BMBCh FRCA is a Specialist Registrar in Anaesthesia at
Cambridge University Hospitals NHS Foundation Trust, Addenbrooke’s
Hospital, Cambridge, UK. Conflicts of interest: none declared.
Daniel Wheeler DM PhD MRCP FRCA is a lecturer in Anaesthesia at the
University of Cambridge and an Honorary Consultant Anaesthetist
at Addenbrooke’s Hospital Cambridge. Conflicts of interest: none
declared.
SURGERY 27:5
Levels of care defined by the Department of Health
Level Description
0 Patients whose needs can be met through normal
ward care in an acute hospital
1 Patients at risk of their condition deteriorating, or
those recently relocated from higher levels of care
whose needs can be met on an acute ward with
additional advice and support from the critical
care team
2 Patients requiring more detailed observation or
intervention, including support for a single failing
organ system or postoperative care, and those
stepping down from higher levels of care
3 Patients requiring advanced respiratory support
alone or basic respiratory support together with
support of at least two organ systems. This level
includes all complex patients requiring support
for multi-organ failure
From UK Department of Health.1
Table 1
In response to this, in 2002 the Intensive Care Society expanded
on these levels of care with clearer illustrations of what might
be appropriate at each level (Table 2).2 Referral on to the next
step must be taken when it is recognized a patient’s level of
­physiological derangement cannot be monitored or managed in
their current clinical area. It is this that forms a large part of the
criteria for admission to critical care.
Timing of admission
In certain surgical patients admission to critical care is a planned
event, owing to either patient, surgical or organizational fac-
tors (Table 3). It may also become apparent during surgery that
patients will require more support than originally planned, for
example because of excessive bleeding or aspiration of gastric
contents. Surgery is also being undertaken on an increasingly
elderly population with substantial co-morbidities. It is the role
of the surgeon and anaesthetist to identify the extent to which
the patient’s physiological status can be optimized before surgery
to improve outcome.
Surgery increases the body’s metabolic needs; these are usu-
ally met by increasing tissue oxygen delivery. Patients must
be assessed to identify those at increased risk of postoperative
hypoxaemia or organ hypoperfusion to allow optimization,
avoiding organ dysfunction or failure.
Oxygen supply to the heart depends on adequate time in dias-
tole to allow flow within the coronary arteries. Therefore, hypox-
aemia, hypotension and tachycardia decrease myocardial oxygen
supply and increase demand causing ischaemia, especially in
patients with pre-existing coronary artery disease. If oxygen
demand remains unmet, ischaemia may progress to infarction,
which carries a perioperative mortality rate of 50%. Hypoten-
sion is defined as inadequate perfusion of vital organs; it may
201 © 2009 Elsevier Ltd. All rights reserved.
 Critical illness and intensive care I
Levels of critical care for adult patients defined by the Intensive Care Society
System Level 0–1
General Patient recently discharged from
a higher level of care
Patients in need of additional
monitoring, clinical input or
advice.
Patients requiring critical care
outreach service support
Patients requiring staff with
special expertise and/or
additional facilities for at least
one aspect of critical care
delivered in a general ward
environment
Respiratory Supplementary oxygen therapy
Patients with long-term
tracheostomy who do not require
respiratory support
Cardiovascular Observations required at least
4 hourly
CNS
Renal Renal replacement therapy (stable
chronic renal failure)
From the Intensive Care Society.2
Table 2
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Level 2 Level 3
Patients needing single-organ system Patients needing advanced respiratory
monitoring and support monitoring and support
Patients needing preoperative Patients needing monitoring and support
optimization for two or more organ systems
Patients needing extended Patients with chronic impairment of
postoperative care one or more organ systems sufficient
to restrict daily activities (co-morbidity)
and who require support for an acute
reversible failure of another organ
system
Patients needing a greater degree of
observation and monitoring
Patients moving to step-down care
Patients with major uncorrected
physiological abnormalities
Needing more than 50% inspired Respiratory failure from any cause that
oxygen. requires invasive, positive-pressure
mechanical ventilatory support
Within 24 hours of tracheostomy Bi-level positive airway pressure via any
insertion form of tracheal tube
Requiring non-invasive ventilation or Extracorporeal respiratory support
continuous positive airway pressure
Requiring physiotherapy or suctioning
at least every 2 hours
Respiratory rate  >  40 breaths/minute
or  >  30 breaths/minute for  >  6 hours
Unstable, requiring continuous ECG Continuous intravenous vasoactive drugs
and invasive pressure monitoring
Haemodynamic instability due to
hypovolaemia/haemorrhage/sepsis
Requiring single infusion of vasoactive
drug with appropriate monitoring
Heart rate  >  120 beats/minute
Hypotension, e.g. systolic blood
pressure  <  80  mm Hg for  >  1 hour
CNS depression sufficient to prejudice Continuous intravenous medication to
airway and protective reflexes control seizures and supplementary
oxygen/airway monitoring
Invasive neurological monitoring.
Glasgow Coma Score  <  10 and at risk
of acute deterioration
Acute impairment of renal, electrolyte Renal in addition to another organ
or metabolic function system failure
202 © 2009 Elsevier Ltd. All rights reserved.
 Critical illness and intensive care I
Factors affecting critical care admission
Factor Examples
Physiological reserve Proxies for this include age
and chronic health status
Abnormal physiological values The most important are
probably respiratory rate, heart
rate, oxygen saturation (SaO2)
and level of consciousness
Underlying condition/surgery Malignancy
Cardiorespiratory dysfunction
Complex surgery
Interventions or monitoring Physiological monitoring
required Regional analgesia
Body cavity drainage
From the Intensive Care Society.2
Table 3
be caused by hypovolaemia, cardiac failure, arrhythmias, drugs,
or spinal or epidural anaesthesia. Persistent hypoperfusion of
vital organs causes irreversible damage, leading to kidney, brain
or gut failure. Adequate perfusion is also required for healing;
­hypotension can be a factor in anastomotic breakdown.
Modified Early Warning Score (MEWS) algorithm
MEWS score
Score ≤ 3 but you are
Score 3
instinctively concerned
Continue present Inform shift charge and
treatment plan critical care outreach team
Record observations and MEWS
at least hourly for 4 hours
Establish: Oxygen therapy
Venous access
12-lead ECG
Blood glucose
Yes
Reduce frequency of observations
and MEWS to 2 hourly for 4 hours.
If MEWS remains ≤ 3 reduce frequency
of observations to 4 hourly
Figure 1
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As well as optimizing patients before operation it is essential
to identify the early warning signs of impending deterioration
and to intervene promptly. The National Confidential Enquiry
into Perioperative Deaths found that most perioperative deaths
occur more than 5 days after surgery. It has emphasized the need
for guidelines to determine which patients should be referred for
critical care review.
Early warning scores
Track and trigger (TT) systems have been introduced to ­ identify
patients at risk of deterioration, and to ensure that they are
reviewed and treated by the appropriate outreach team or clinician.
Most employ the recording of standard physiological parameters
which trigger a response if they lie outside a pre-determined range.
In the UK many of these systems are based on an early warning
score (EWS) (Figure 1, Table 4), whereas Australia uses the medi-
cal emergency team (MET) model. A systematic review found there
to be a variety of systems in use, many with little evidence for their
validity, having low sensitivities and positive predictive values
but with acceptable specificities and negative predictive values.3
Lowering the thresholds for a response could improve sensitivity
but at increased cost, greater manpower being required to respond
to the increased number of triggering events.
A London hospital evaluated its local EWS by scoring 433
non-obstetric patients on a single-day audit; the 30-day mortality
was 6%. Those who died were significantly older and had longer
hospital stays. Mortality increased with an increasing ­ number
Score 3 Score ≥ 4
Inform:
1 Shift charge
Inform shift change
2 Critical care outreach team
3 Patient’s medical team
Consider: Fluid resuscitation
ABG, biochemistry,
haematology, septic screen
Urinary catheter
Critical care review
Pain control
No
MEWS ≤ 3 Continue hourly observations
MEWS ≥ 4
203 © 2009 Elsevier Ltd. All rights reserved.
 Critical illness and intensive care I

Modified Early Warning Score used in Addenbrooke’s Hospital, Cambridge, UK

Variable MEWS score

3 2 1 0 1 2 3

Heart rate ≤40 41–50 51–60 61–90 91–110 111–129 ≥130

(beats/minute)
Respiratory rate ≤6 7–8 9–14 15–20 21–29 ≥30
(breaths/minute)
Systolic blood ≤70 71–80 81–100 101–180 >180
pressure (mm Hg)
AVPU/GCS Unresponsive Pain Voice Alert or Confused or 9–13 ≤8
GCS 15/15 GCS 14/15
Urine output <10  ml 0.5  ml/kg in <1  ml/kg/hour Has not passed Has not passed >400  ml/hour or
(catheterized) 2 hours or urine for 6 urine for 12 has not passed
30  ml/hour hours (not hours (not urine for  >  12 hours
catheterized) catheterized) (not catheterized)
Temperature (°C) <35 35–38.4 38.5–39 >39

AVPU, Alert, Voice, Pain, Unresponsive; GCS, Glasgow Coma Score; MEWS, Modified Early Warning Score.

Table 4

of abnormal physiological variables. Level of consciousness,

heart rate, age, systolic blood pressure and respiratory rate were
important predictive variables. There is no current evidence that
TT systems reduce mortality; they should be used to complement
clinical judgement, not in isolation.
Critical care outreach
Another recommendation of ‘Comprehensive critical care’ was
the introduction of critical care outreach services (CCOS). Their
objectives are to avert or ensure timely critical care admission,
to enable prompt discharge from critical care and to share skills
with ward staff. This document did not provide any models for
CCOS and they were introduced without any prospective evalu-
ation. A multicentre analysis of CCOS participating in the Case
Mix Programme had interesting findings.4 The introduction of
CCOS had no significant effect on the proportion of all admissions
coming from the ward. CCOS significantly reduced the amount
of ­cardiopulmonary resuscitation (CPR) in the 24 hours preced-
ing admission, admissions out of hours (between 2200 and 0659
hours) and the mean Intensive Care National Audit and Research
Centre (ICNARC) physiology score. The additional use of TT
warning systems reduced rates of CPR before admission. There
was no effect on mortality rates of patients admitted, mortality
after discharge from critical care or readmission rates. This paper
did not show any clear benefit to the introduction of CCOS. Stud-
ies of METs in Australia have shown a benefit to patients under-
going major surgery; there were fewer adverse events, decreased
emergency ICU admissions and fewer postoperative deaths.
The Cochrane Collaboration has reviewed both outreach
services and EWS.5 It found only two randomized controlled
trials appropriate for inclusion in its review. Evidence to sup-
port CCOS and EWS in reducing hospital mortality, unplanned
ICU admission, readmission and length of hospital stay was
­inconclusive.
Severity of illness scoring
Scoring systems have been developed to assess single disease
states and global health status, as a research tool and as a
­mechanism for assessing the performance of critical care units.
These scoring systems can be used to generate a standardized
mortality ratio, the ratio of actual to predicted mortality for each
unit. This takes into account factors such as case mix (differ-
ences in the pre-morbid health of patients) to allow an unbiased
comparison of different units or the same unit over time. Most
of these systems were developed in North America; it is unclear
how they apply to other populations. Most systems evaluate the
patient’s condition on arrival in the ICU but do not take into
account treatment received in theatre, the emergency department
or on the ward beforehand. Lead-time bias may affect the calcu-
lated severity score and apparent unit performance.
Physiological scores
Physiological scores are summarized in Table 5.
American Society of Anesthesiologists (ASA) grade: this system
has been in use since 1963. It grades preoperative patients from I
to V according to the degree of systemic illness, with the addition
of the tag of emergency when indicated (Table 6). Although it is
subjective, it is simple and it has been shown repeatedly that risk
of mortality increases with increasing ASA grade; 50% of surgical
deaths are in patients with an ASA score of IV or V.
Acute Physiology And Chronic Health Evaluation (APACHE):
the APACHE model was first developed in 1981 with data from
two American ICUs; it included 34 physiological variables in
addition to an assessment of chronic ill health. The simplified
APACHE II included data from 13 American hospitals, relying
on only 12 variables to create the acute physiology score (APS).

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 Critical illness and intensive care I

Summary of physiological scoring systems

Scoring System Date published Origin of patient database Variables in APS Time of data collection Exclusions

APACHE II 1985 USA 12 First 24 hours <16 years

APACHE IV 2006 USA 16 First 24 hours <16 years
SAPS II 1994 USA/Europe 13 First 24 hours <18 years, coronary care,
burns and cardiac surgery
SAPS III 2005 Global 10 Admission +/− 1 hour <16 years
MPM0-II 1993 USA/Europe 15 First hour <18 years, coronary care,
burns and cardiac surgery
MPM0-III 2007 USA/Europe 16 First hour <18 years, coronary care,
burns and cardiac surgery
POSSUM 1991 UK 12 Any Non-operative patients
ICNARC 2007 UK 12 First 24 hours None

APS, acute physiology score; APACHE, Acute Physiology And Chronic Health Evaluation; ICNARC, Intensive Care National Audit and Research Centre; MPM, Mortal-
ity Prediction Model; POSSUM, Physiology and Operative Severity Score for EnUmeration of Mortality and morbidity; SAPS, Simplified Acute Physiology Score.

Table 5

The further addition of the chronic health evaluation, age and
urgency of admission undergo logistic regression to give the total
APACHE score, a probability of mortality. APACHE III was devel-
oped with data from an expanded set of 40 American hospitals
and an 18-value APS. The statistical models used for this system
have not been in the public domain so it has not been as widely
used and validated as the first two models. Recently APACHE
IV was published in response to the decreasing accuracy of the
­previous versions.6 This is believed to be due to changes in out-
come with time given advances in medical care and improve-
ments in end-of-life decision making. APACHE II is still in most
common use owing to its simplicity and numerous validation
studies, but the APACHE authors have requested that APACHE II
no longer be used, except in patients with severe septis, so that
the newer models can be validated.
Simplified Acute Physiology Score (SAPS) employed 14 of the
original 34 variables of APACHE. The most recent iteration is
SAPS III which also includes patient characteristics before admis-
sion and circumstances of admission. The dataset came from an
international group of patients; the predictive value varies glob-
ally, with performance being best in North Europe.
Mortality Prediction Model (MPM) was first developed in the
late 1980s and included data on pathology only. The MPM at
ICU admission version 2 (MPM0-II) was developed from data
­collected from an international group of patients. The data are
collected from the first hour of a patient’s admission to the ICU.
It was felt that this model overpredicted mortality so MPM-III
was developed from a dataset of 124,885 patients.7 This model
uses 16 variables recorded on admission to predict mortality.
One advantage of this system is that it can be repeated at 24,
48 and 72 hours to track changes during a critical care stay.
Again it has been refined over the years to improve calibration.7
The most recent version (MPM0-III) is best employed on general
ICUs as it excludes children, patients with burns and cardiac
patients.

Physiology and Operative Severity Score for EnUmeration of

American Society of Anesthesiologists grades Mortality and morbidity (POSSUM): unlike the other systems
discussed this was developed for use in surgical patients. Simi-
ASA grade Definition Mortality
lar to the others, it was developed for audit and not individual
I Normal healthy individual 0.05 patient prognosis. It employs a combination of physiological
II Mild systemic disease that does not 0.4 derangement and an operative severity score (OSS). This OSS
limit activity means that the system is applicable only to operative surgical
III Severe systemic disease that limits 4.5 patients, excluding the one-third of patients who are managed
activity but is not incapacitating non-operatively.
IV Incapacitating systemic disease that 25
constantly threatens life ICNARC: APACHE II was developed from US data and the UK
V Moribund, not expected to survive 50 APACHE II study validated this model in UK patients. This led
24 hours to the development of the Case Mix Programme as an ongoing
national critical care audit and the ICNARC model.8 ICNARC
ASA, American Society of Anesthesiologists. differs from other systems by employing a diagnostic cate-
gory to account for the fact that a patient with diabetic keto-
Table 6 acidosis will have a lower risk of mortality than a patient with ­­

SURGERY 27:5 205 © 2009 Elsevier Ltd. All rights reserved.

 Critical illness and intensive care I
intra-­abdominal sepsis, given the same degree of physiological
derangement. ICNARC allows a less biased appraisal of ICUs
with different admission case mixes. It also includes patients
who have been excluded from other models, such as children
and burns patients. The resulting model is therefore applicable
to a larger range of UK patients and is less biased when compar-
ing different ICUs.
Anatomical scores
Disease and organ-specific systems include the Glasgow Coma
Score (GCS), Ranson pancreatitis score and Child–Pugh liver fail-
ure classification. The use of these is not limited to critical care
and they can be useful in documenting disease severity. The GCS
was originally developed for use in trauma patients and traumatic
brain injury, but its use is now far more widespread. In terms of
critical care, it should be used only in specialist neurointensive
care units and not to describe patients who are unconscious for
other reasons.
Organ dysfunction scores
Most of the systems described above are static; they assess
patients only on admission or within the first 24 hours of admis-
sion to critical care. In many cases organ and physiological func-
tion fluctuate following admission, so dynamic scoring might
therefore be more appropriate.
Sepsis-related Organ Failure Score (SOFA) was published in
1994 by the European Society of Intensive Care Medicine fol-
lowing a consensus conference. It involves daily scoring of six
organ systems to allow an organ-by-organ, total or worst-during-
admission score. Although it was developed to be independent of
treatment, the cardiovascular score includes use of a vasoactive
drug. This system has been validated in both a retrospective and
prospective study.
Multiple Organ Dysfunction Score (MODS) scores six organ sys-
tems on a scale from 0 to 4, where 0 is essentially normal func-
tion and the maximum total score is 24. MODS correlates with
ICU outcome, and can be used to assess prognosis on admission
and as an outcome measure, tracking organ dysfunction as it
varies during ICU admission.9 Unlike other scoring systems that
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were developed from a patient database, MODS was developed
from published clinical studies.
Conclusion
This article has focused on who to admit to the ICU and when.
We must also not lose sight of those patients for whom admis-
sion is inappropriate. Scoring systems may guide us but clinical
judgement and sensitive communication remain core skills when
dealing with end-of-life events and decisions. ◆
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206 © 2009 Elsevier Ltd. All rights reserved.