Determinants and outcomes associated with decisions to deny intensive care unit admission in Tunisian ICU (original) (raw)

Determinants and outcomes associated with decisions to deny or to delay intensive care unit admission in Morocco

Intensive Care Medicine, 2012

Purpose: To report determinants and outcomes associated with decisions to deny or to delay intensive care unit (ICU) admission in critically ill patients. Methods: An observational prospective study over a 6-month period. All adult patients triaged for admission to a medical ICU were included prospectively. Age, gender, reasons for requesting ICU admission, severity of underlying disease, severity of acute illness, mortality and ICU characteristics were recorded. Multinomial logistic regression analysis was used for evaluating predicting factors of refused ICU admission. Results: ICU admission was requested for 398 patients: 110 were immediately admitted (27.8%), 142 were never admitted (35.6%), and 146 were admitted at a later time (36.6%). The reasons for refusal were: too sick to benefit (31, 10.8%), too well to benefit (55, 19.1%), unit full (117, 40.6%), and more data about the patient were needed to make a decision 29.5%). Multivariate analysis revealed that late ICU admission was associated with the lack of available ICU beds (OR 1.91; 95% CI 1.46-2.50; p = 0.003), cardiac disease (OR 7.77; 95% CI 2.41-25.04; p \ 0.001), neurological disease (OR 3.78; 95% CI 1.40-10.26; p = 0.009), shock and sepsis (OR 2.55; 95% CI 1.06-6.13; p = 0.03), and metabolic disease (OR 2.84; 95% CI 1.11-7.30; p = 0.02). Factors for ICU refusal for never admitted patients were: severity of acute illness (OR 4.83; 95% CI 1.11-21.01; p = 0.03), cardiac disease (OR 14.26; 95% CI 3.95-51.44;

Reasons for refusal of admission to intensive care and impact on mortality

Intensive Care Medicine, 2010

Purpose: To identify factors influencing triage decisions and investigate whether admission to the intensive care unit (ICU) could reduce mortality compared with treatment on the ward. Methods: A multicentre cohort study in 11 university hospitals from seven countries, evaluating triage decisions and outcomes of patients referred for admission to ICU who were either accepted, or refused and treated on the ward. Confounding in the estimation of the effect of ICU admission on mortality was controlled by use of a propensity score approach, which adjusted for the probability of being admitted. Variability across centres was accounted for in both analyses of factors influencing ICU admission and effect of ICU admission on mortality. Results: Eligible were 8,616 triages in 7,877 patients referred for ICU admission. Variables positively associated with probability of being admitted to ICU included: ventilators in ward; bed availability; Karnofsky score; absence of comorbidity; presence of haematological malignancy; emergency surgery and elective surgery (versus medical treatment); trauma, vascular involvement, liver involvement; acute physiologic score II; ICU treatment (versus ICU observation). Multiple triages during patient's hospital stay and age were negatively associated with ICU admission. The area under the receiver operating characteristic (ROC) curve of the model was 0.83 [95% confidence interval (CI): 0.81-0.84], with Hosmer-Lemeshow test P = 0.300. ICU admission was associated with a statistically significant reduction of both 28-day mortality [odds ratio (OR): 0.73; 95% CI: 0.62-0.87] and 90-day mortality (0.79; 0.66-0.93). The benefit of ICU admission increased substantially in

Factors Associated with Intensive Care Unit Admission Refusal

Annals of African Surgery

Background: The need for intensive care exceeds its availability most times because resources are limited. Our objectives were to determine the incidence of admission refusal and factors associated with such in our Intensive Care Unit (ICU). Methods: The following information was obtained from patients referred to our ICU over a 6-week period: age, gender, date and time of referral, source of referral, reason for referral, whether ICU was full or not full at the time of referral, and modified early warning score (MEWS). Others included; whether admitted or not, and if not admitted, reasons for admission refusal. Binomial logistic regression analysis was used to determine predictors of ICU admission refusal. Results: Patients admitted and those denied admission were 37(50.7%) and 36(49.3%) respectively. Following univariate analysis, there were no statistical differences in the age and MEWS of patients in the admitted and not admitted groups

Patient-related factors and circumstances surrounding decisions to forego life-sustaining treatment, including intensive care unit admission refusal*

Critical Care Medicine, 2008

To assess decisions to forego life-sustaining treatment (LST) in patients too sick for intensive care unit (ICU) admission, comparatively to patients admitted to the ICU. Design: Prospective observational cohort study. Setting: A medical-surgical ICU. Patients: Consecutive patients referred to the ICU during a one-yr period. Intervention: None. Measurements and Main Results: Of 898 triaged patients, 147 were deemed too well to benefit from ICU admission. Decisions to forego LST were made in 148 of 666 (22.2%) admitted patients and in all 85 patients deemed too sick for ICU admission. Independent predictors of decisions to forego LST at ICU refusal rather than after ICU admission were: age; underlying disease; living in an institution; preexisting cognitive impairment; admission for medical reasons; and acute cardiac failure, acute central neurologic illness, or sepsis. Hospital mortality after decisions to forego LST was not significantly different in refused and admitted patients (77.5% vs. 86.5%; p ‫؍‬ .1). Decisions to forego LST were

Profile of ICU Bed Requests at Helen Joseph Hospital

Wits Journal of Clinical Medicine, 2020

Background: Intensive care unit (ICU) beds are a scarce resource at Helen Joseph Hospital (HJH). A limited number of beds serve a population with a large burden of disease. Medical practitioners request ICU beds for patients they deem in need of ICU management. However, the decision to admit patients to the ICU remains the responsibility of the ICU consultant on call. No formal prognostic scoring system (such as Acute Physiological and Chronic Health Evaluation or Simplified Acute Physiology Score) or admission guidelines were in place when performing this study. Aim: To compile a profile of all the ICU admission requests at HJH. Methods: A contextual, prospective, descriptive research design was followed in this study. Data was collected during one winter and one summer month in 2012 using consecutive sampling from ICU consultation forms. Results: A total of 139 patients were included in the study. The median age was 44 years. The majority of patients (79%) were under the age of 60 years. The overall admission rate was 35.25% and the most common reason for admission was mechanical ventilation. Of the patients refused ICU admission, 41% were assessed as being too ill, 30% were assessed as too well and 29% were refused admission due to a lack of resources. Patients admitted to the ICU had a 77.55% survival rate. The relationship between ICU admission and 30-day improved outcome was statistically significant, with those being admitted to ICU having a better outcome. Conclusions: Overall a relatively young population is admitted to ICU at HJH. The allocation of beds between the disciplines is fairly equal, both with good survival benefits. The lack of ICU resources is an important limitation to ICU admission. Admission to ICU demonstrated a survival benefit.

The Financial Burden of Inappropriate Admissions to Intensive Care Units of Shahid Faghihi and Nemazee Hospitals of Shiraz, Iran, 2014

shiraz e medical journal, 2016

Background: Investigating the conditions and the appropriateness of admission of patients in hospitals is an important issue which can improve the efficiency of health care delivery. Intensive care unit (ICU) is important due to applying expensive financial sources; therefore, its efficient application is of great priority. In this regard, the current study aimed to determine the financial burden of inappropriate admissions in internal intensive care units (IICUs). Methods: It was a cross-sectional study conducted in 2014. A total of 294 patients admitted to IICUs of Shahid Faghihi and Nemazee hospitals of Shiraz, Iran, in 2012 were enrolled into this retrospective study. The study was conducted in two phases, using the guidelines of American critical care association (ACCA) and experts' opinion to investigate the financial burden of inappropriate admissions in IICUs of the above-mentioned hospitals. Results: The results showed no statistically significant relationships among insurance status, insurance type, age, gender and inappropriate admission by applying Chi-square. Among 294 admitted patients under the study, the inappropriate admissions were 11.2% based on the guidelines and 13.6% based on the experts' opinion. The level of agreement of the guidelines and experts' opinion for the inappropriate admissions was 0.076 based on Kappa coefficient. The total financial burden imposed on the insurance agencies and the patients by inappropriate admissions was US$ 47867.78 based on the guidelines and US$ 83241.68 based on the experts' opinion. Conclusions: Inappropriate admissions to ICUs may impose additional costs to the health system and the patients on one hand, and deprives other patients from receiving health services. Therefore, it is crucial to effectively plan for the application of ICU beds.

Physicians’ Views and Agreement about Patient- and Context-Related Factors Influencing ICU Admission Decisions: A Prospective Study

Journal of Clinical Medicine, 2021

Background: Single patient- and context-related factors have been associated with admission decisions to intensive care. How physicians weigh various factors and integrate them into the decision-making process is not well known. Objectives: First, to determine which patient- and context-related factors influence admission decisions according to physicians, and their agreement about these determinants; and second, to examine whether there are differences for patients with and without advanced disease. Method: This study was conducted in one tertiary hospital. Consecutive ICU consultations for medical inpatients were prospectively included. Involved physicians, i.e., internists and intensivists, rated the importance of 13 factors for each decision on a Likert scale (1 = negligible to 5 = predominant). We cross-tabulated these factors by presence or absence of advanced disease and examined the degree of agreement between internists and intensivists using the kappa statistic. Results: O...

Triage decisions for ICU admission: Report from the Task Force of the World Federation of Societies of Intensive and Critical Care Medicine

Journal of critical care, 2016

Demand for intensive care unit (ICU) resources often exceeds supply, and shortages of ICU beds and staff are likely to persist. Triage requires careful weighing of the benefits and risks involved in ICU admission while striving to guarantee fair distribution of available resources. We must ensure that the patients who occupy ICU beds are those most likely to benefit from the ICU's specialized technology and professionals. Although prognosticating is not an exact science, preference should be given to patients who are more likely to survive if admitted to the ICU but unlikely to survive or likely to have more significant morbidity if not admitted. To provide general guidance for intensivists in ICU triage decisions, a task force of the World Federation of Societies of Intensive and Critical Care Medicine addressed 4 basic questions regarding this process. The team made recommendations and concluded that triage should be led by intensivists considering input from nurses, emergency...

Factors influencing triage decisions in patients referred for ICU admission

Journal of clinical medicine research, 2013

Few data is available on triage of critically ill patients. Because the demand for ICU beds often exceeds their availability, frequently intensivists need to triage these patients in order to equally and efficiently distribute the available resources based on the concept of potential benefit and reasonable chance of recovery. The objective of this study is to evaluate factors influencing triage decisions among patients referred for ICU admission and to assess its impact in outcome. A single-center, prospective, observational study of 165 consecutive triage evaluations was conducted in patients referred for ICU admission that were either accepted, or refused and treated on the medical or surgical wards as well as the step-down and telemetry units. Seventy-one patients (43.0%) were accepted for ICU admission. Mean Acute Physiology and Chronic Health Evaluation (APACHE)-II score was 15.3 (0 - 36) and 13.9 (0 - 30) for accepted and refused patients, respectively. Three patients (4.2%) h...