ICU Admission, Discharge,

and Triage Guidelines:

A Framework to Enhance Clinical Operations,
Development of Institutional Policies, and Further
Research

Christopher Ryalino
Division of Anesthesiology, Critical Care, and Pain Medicine
RSUD Genteng, Kabupaten Banyuwangi
RSU Bakti Husada, Glenmore
RS Al-Huda, Genteng
RS Nahdlatul Ulama, Mangir
POINTS OF CONSIDERATION IN ADMISSION

1. Specific patient needs that can be only addressed in the ICU

environment, such as life-supportive therapies
2. Available clinical expertise
3. Prioritization according to the patient’s condition
4. Diagnosis
5. Bed availability
6. Objective parameters at the time of referral, such as respiratory
rate
7. Potential for the patient to benefit from interventions
8. Prognosis
DIAGNOSTIC MODEL IN ICU ADMISSION

▪ Uses specific conditions or diseases to determine appropriateness

of ICU admission
▪ 48 diagnosis in 8 organ systems
– Acute MI with complications
– cardiogenic shock
– complex arrhythmias
– acute respiratory failure
– status epilepticus
– SAH
– etc
 OBJECTIVE PARAMETERS MODEL

VITAL SIGNS LAB VALUES RADIOLOGIC AND ECG FINDINGS ACUTE PHYSICAL
FINDINGS
HR < 40 or > 150 Sodium < 110 or > 170 ICH, SAH, contusion with AMS or unequal pupils with LOC
SBP <80 Potassium <2.0 or > 7.0 focal neuro signs burns > 10%TBSA
MAP <60 PaO2 < 50 Ruptured viscera, bladder, liver, anuria
pH < 7.1 or > 7.7 uterus with hemodynamic airway obstruction
DBP >120
Glucose > 800 mg/dL instability coma
RR > 35
Calcium > 15 mg/dL Dissecting aorta continuous seizures
toxic drug level cyanosis
cardiac tamponade
post major surgery
 PRIORITIZATION MODEL IN ICU ADMISSION

Priority Condition Example

1 Critically ill, unstable patients, who require Patients require invasive ventilation, CRRT, invasive
life support for organ failure, intensive hemodynamic monitoring, respiratory insufficiency
monitoring, and therapies that can only tolerating intermittent non-invasive ventilation.
provided in the ICU environment.
2 Require intensive monitoring, and Patients with chronic comorbidities with acute severe
may potentially need immediate circulatory illnesses, impending circulatory and/or respiratory failures
and/or respiratory interventions.
3 Those who are critically ill with reduced Metastatic cancer complicated by sepsis, infection,
likelihood of recovery. tamponade, airway obstrucition.
4 Generally not appropriate for ICU. May Too well for ICU (mild CHF, stable DKA, conscious drug
admit on individual basis in unusual overdose, peripheral vascular surgery.
circumstances (usually social circumstances) Too sick for ICU (terminal, irreversible)
5 Terminal or moribund patients with no Palliative care patients.
possibility of recovery.
DISCHARGE CRITERIA

▪ Physiologic status has stabilized

– need for ICU monitoring and care no longer necessary
▪ Physiologic status has deteriorated
– active interventions no longer planned
▪ Why they were in, that’s why they were out
– sometimes may not be so simple
▪ Parameter based (subjective and objective findings, lab
values, radiologic findings, etc)
LEARN THE COMMON CRITICAL VALUES
Test LL UL Test LL UL
BP 70 mmHg 180 mmHg pH 7,3 7,5
HR 60 bpm 140 bpm pCO2 25 60
RR 8 bpm 30 bpm SaO2 88%
Temperature 40 °C Hb 6 g/dL
Pain score 7 Blood sugar 60 mg/dL 400 mg/dL
GCS 9 Sodium 120 mmol/L 150 mmol/L
Urine prod 1,0 mL/kg/h Potassium 2,5 mmol/L 6 mmol/L
CRITICAL PATIENTS: input state
determines outcome
Which of these need your attention the first?

112 92 88 98 62 93
79 / 58 195 / 105 82 / 62
(65) (135) (69)
22 16 22