Hospital and Intensive Care Unit Admission Decisions: How Do I Know?

Whether working in the pediatric urgent care or in the hospital, I come across children whom I have to decide whether or not they need to be sent to the hospital or, if they are already in the hospital, whether or not they need to be admitted to the intensive care unit. This comes under the umbrella term of triage. Triage means “the assignment of degrees of urgency to wounds or illness to decide the order of treatment of a large number of patients or casualties.” It is true that this term usually applies to more large-scale catastrophes, but it can also apply on the small scale of an individual patient to decide where their treatment will be the most appropriate.

In the urgent care setting, one has to decide:

1. Can this child be sent home, safely, without something bad happening to them at home…as a consequence of their illness or injury?

2. Will the family be able to care for their child appropriately at home, given the severity of the illness or injury?

Similar questions can be asked in the hospital setting, when one is deciding to admit a child to the intensive care unit:

1. Can this child stay on the pediatric ward (regular in-patient floor), safely, without something bad happening to them on the regular ward…as a consequence of their illness or injury?

2. Will the pediatric ward team be able to care for their child appropriately on the regular ward, given the severity of illness or injury?

The pattern of decision making is very similar and the overall question is, “does this child require a higher level of care for their illness or injury?” This can be determined by the complexity and severity of the illness or injury or the sheer amount of care that is required to treat the illness or injury.

As an example, I have seen many infants present with symptoms of respiratory syncytial virus (RSV) that causes increased mucous production and narrowing of small airways in the lungs. This will result in trouble breathing. The spectrum of illness ranges from a mild “cold” with cough and runny nose to respiratory distress or failure that requires intubation and mechanical ventilation. Along those lines, I have to decide:

1. How much trouble breathing is the infant having?

2. Can the infant’s symptoms be relieved by suctioning the mucous out of the nose or mouth and will that improve the breathing?

3. If the infant’s symptoms are relieved by the suctioning, how often does that suctioning need to be performed?

So, if an infant is having worse trouble breathing and requiring more frequent suctioning of mucous to relieve the symptoms or the suctioning is not improving the breathing, the infant will require a higher level of care…either from urgent care to hospital or regular hospital ward to the intensive care unit. This example of the medical decision-making process is the crux to determining whether or not I admit a child to the hospital or intensive care unit.

Do you think that there should be other criteria involved in this medical decision-making process that I did not cover?