title: Prospective evaluation of patients refused admission to an intensive care unit: triage, futility and outcome.
abstract: OBJECTIVE
  To evaluate factors associated with decisions to refuse ICU admission and to assess the outcome of refused patients.
  
  
  METHODS
  Prospective, descriptive evaluation in a multi-disciplinary intensive care unit, university referral hospital.
  
  
  METHODS
  All adult emergency referrals over a 7-month period.
  
  
  METHODS
  The number of beds available at the time of referral, the patient's age, gender, diagnosis, mortality probability model score and hospital survival were documented. The outcome of the referral and the reason for refusal were recorded.
  
  
  RESULTS
  Of 624 patients 388 were admitted and 236 (38%) refused. Reasons for refusal were triage (n=104), futility (n=82) and inappropriate referral (too well; n=50). The standardised mortality ratio (SMR) for refused and admitted groups was 1.24 (95% CI 1.05-1.46) and 0.93 (0.78-1.09) respectively. The SMR ratio (refused SMR/admitted SMR) was highest in the middle range of illness (1.95, 1.19-3.20). Inappropriate referrals had a better than expected outcome despite refusal, with a SMR ratio of 0.39 (0.11-0.99). Excluding inappropriate referrals, multivariate analysis demonstrated that refusal was associated with older age, diagnostic group and severity of illness. Triage decisions were associated with a diagnosis of sepsis, and futility decisions with greater severity of illness and recent cardiac arrest.
  
  
  CONCLUSIONS
  Refusal of admission to our ICU is common. Excess mortality of patients refused is most marked in the middle range of severity of illness. Age, diagnostic group, and severity of illness are important in decision making. Strategies should be developed to create admission criteria that would identify patients in the middle range of severity of illness who should benefit most from ICU care.
authors.affiliation: Department of Anaesthesia and Intensive Care, Chinese University of Hong Kong, Prince of Wales Hospital, Sha Tin, Hong Kong, P.R.C. gavinmjoynt@cuhk.edu.hk
authors.forename: G M
authors.initials: GM
authors.lastname: Joynt
authors.forename: C D
authors.initials: CD
authors.lastname: Gomersall
authors.forename: P
authors.initials: P
authors.lastname: Tan
authors.forename: A
authors.initials: A
authors.lastname: Lee
authors.forename: C A
authors.initials: CA
authors.lastname: Cheng
authors.forename: E L
authors.initials: EL
authors.lastname: Wong
mesh_terms: D000293:Adolescent; D000328:Adult; D000367:Age Factors; D000368:Aged; D000369:Aged, 80 and over; D001509:Bed Occupancy / Q000706:statistics & numerical data; D016638:Critical Illness / Q000145:classification* / Q000401:mortality / Q000628:therapy; D003659:Decision Making, Organizational; D003953:Diagnosis-Related Groups / Q000145:classification / Q000706:statistics & numerical data; D005260:Female; D015276:Health Care Rationing / Q000458:organization & administration*; D006302:Health Services Research; D006723:Hong Kong / Q000453:epidemiology; D017052:Hospital Mortality; D006785:Hospitals, University / Q000592:standards / Q000706:statistics & numerical data*; D006801:Humans; D007362:Intensive Care Units / Q000706:statistics & numerical data*; D016015:Logistic Models; D008297:Male; D018447:Medical Futility; D008875:Middle Aged; D015999:Multivariate Analysis; D010043:Outcome and Process Assessment, Health Care; D010343:Patient Admission / Q000592:standards / Q000706:statistics & numerical data*; D011446:Prospective Studies; D012017:Referral and Consultation / Q000592:standards*; D012307:Risk Factors; D012720:Severity of Illness Index; D012737:Sex Factors; D016019:Survival Analysis; D014218:Triage / Q000458:organization & administration*