The 2 AM Consultation That Needs an Answer in Eight Minutes
The AED calls. Sixty-three-year-old, septic shock, currently on two pressors, GCS 10, pre-existing severe COPD. The ward has no bed, and the family is asking what happens next. The ICU consultant is the person who has to make the call — admit, reject on prognostic grounds, or hold pending a bed — and document that decision in a way that survives a mortality review.
This template is the consultation record that makes the 2 AM call auditable.
The Organ System Matrix: Nine Systems, Four Levels Each
Nine organ systems are scored on the same four-point scale: 1 = Normal, 2 = Close Monitoring, 3 = Severe/Active intervention, 4 = Terminal/Not for escalation. CVS covers cardiovascular stability — Level 3 is severe shock or arrest; Level 4 is terminal. Respiratory runs to Level 3 = MV/ECMO; Level 4 = terminal. Neurology maps GCS ranges: Level 1 is GCS 13-15, Level 2 is GCS 9-12 or perioperative, Level 3 is GCS 8 or lower, Level 4 is terminal. Renal scores from normal through close monitoring, to active RRT, to terminal or contraindicated for RRT. GI/Liver extends to Level 3 for MARS (Molecular Adsorbent Recirculating System) candidacy — the presence of MARS as a Level 3 endpoint signals a hepatology-integrated ICU. OBS, Endo, and Surg/Trauma complete the matrix.
The elegance of the four-level scale is that it produces a consistent severity language across organ systems. A Resp Level 3 and a CVS Level 3 are both "actively receiving major intervention" — mechanically ventilated and on vasopressors respectively. When a consultant records six Level 3 entries on a single patient, the cumulative picture of multi-organ failure requiring active management emerges from the data pattern without requiring a narrative to communicate it.
SCCM Priority and Background Health: The Triage Framework
SCCM priority applies the Society of Critical Care Medicine's four-tier admission framework: Priority 1 is physiologically unstable and expected to benefit from ICU monitoring and treatment. Priority 2 is for close monitoring without active intervention. Priority 3 is ill but with a poor underlying condition that limits expected benefit from ICU care. Priority 4 is either too good to need ICU (admission would be inappropriate utilization) or too poor to benefit (admission would provide no meaningful advantage over comfort-focused care).
Background health feeds into this: Level 1 is normal, Level 2 is moderate chronic disease, Level 3 is severe (meeting APACHE II chronic health criteria — cirrhosis, heart failure, immunosuppression), Level 4 is terminal. A patient with a Background Health Level 3 has an APACHE chronic health penalty that affects score and prognosis independently of the acute presentation.
ADL status (Independent, With Support, Partially Dependent, Total Dependent) adds the functional baseline: a patient who is totally ADL-dependent before the acute illness has a different expected trajectory for ICU benefit than one who was fully independent.
Final Decision: The Six-Outcome Triage Record
Final decision logs six outcomes: Admit, Reject due to poor prognosis, Tight/No bed, Patient refusal, Too good (doesn't meet threshold for ICU), Others. This field is the primary audit data point for ICU utilization review. A unit logging a high frequency of "Reject due to poor prognosis" decisions has a different triage culture — and different questions to answer — than one logging a high frequency of "Too good" rejections.
Disagree with parent team (Yes/No) is the quality audit field. When the ICU consultant's assessment of the patient's condition or prognosis leads to a different recommendation than the referring team's expectation, that disagreement is documented. A high disagreement rate on a specific ward or unit signals either a referral quality problem — patients being sent to ICU consultation when they don't meet criteria — or a communication breakdown about what ICU can and cannot provide.
Source (AED, Ward, OT, Others) and Type (New, Re-consult within 24 hours, Reassess) complete the call record. Filtering for Type = Re-consult within 24 hours identifies patients whose initial consultation decision needed rapid revision — the clinical instability or new information that changed the picture between the first and second assessment.