Key issues addressing appropriateness of triage decisions and the tools needed to support those decisions are identified in this article. The limitations of current approaches to appropriate utilization such as admission and continued-stay criteria, medical management models, bed control and bed management strategies, and rounding practices are discussed, and a systemic model to examine the placement of patients is proposed. Determining which patients can benefit from critical care and which can benefit from an alternative level of care is analyzed through the use of clinical decision support tools that provide both retrospective analysis of current patterns and predictive models to assist the clinician in making continued-stay decisions. Patient populations who are considered for alternative placement are defined. Those populations identified as having the potential to gain limited benefit from the level of intensity of an intensive care unit are managed in alternative sites. The role played by the advanced practice clinician in using clinical decision support tools is discussed.

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