Reasons for refusal of admission to intensive care and impact on mortality.
OBJECTIVE
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 patients with greater severity of illness.


CONCLUSIONS
We suggest that intensivists take great care to avoid ICU admission of patients judged not severe enough for ICU or with low performance status, and they tend to admit surgical patients more readily than medical patients. Interestingly, they do not judge age per se as a reason for refusal of ICU admission. Admission to ICU was associated with a reduction of both 28- and 90-day mortality, particularly in patients with greater severity of illness at time of triage.
Dipartimento di Anestesiologia, Terapia Intensiva e Scienze Dermatologiche, Università degli Studi di Milano-U.O. Anestesia e Rianimazione, Azienda Ospedaliera Polo Universitario San Paolo, via A. Di Rudinì 8, 20142, Milan, Italy. g.iapichino@unimi.it.
Gaetano
G
Iapichino
Department of Anaesthesia, Montreal Children's Hospital, McGill University, Montreal, QC, Canada.
Davide
D
Corbella
Institute of Genetic Medicine, EURAC Research, Bolzano, Italy.
Cosetta
C
Minelli
Department of Critical Care, Anaesthesia and Operating Services, Sheffield and Medical and Economics Research Centre, Royal Hallamshire and Northern General Hospitals, Sheffield Teaching Hospitals NHS Trust, Sheffield, UK.
Gary H
GH
Mills
Critical Care Center, CIBER Enfermedades Respiratorias, Sabadell Hospital Parc Tauli, University Institut, Autonomous University of Barcelona, Barcelona, Spain.
Antonio
A
Artigas
Faculty of Health and Wellbeing, Sheffield and Medical and Economics Research Centre Sheffield, Royal Hallamshire Hospital, Sheffield Teaching Hospitals NHS Trust, Sheffield Hallam University, Sheffield, UK.
David L
DL
Edbooke
Dipartimento di Anestesiologia, Terapia Intensiva e Scienze Dermatologiche, Università degli Studi di Milano-U.O. Anestesia e Rianimazione, Azienda Ospedaliera Polo Universitario San Paolo, via A. Di Rudinì 8, 20142, Milan, Italy.
Angelo
A
Pezzi
University Medical Centre, Utrecht, The Netherlands.
Jozef
J
Kesecioglu
Dipartimento di Medicina Perioperatoria e Terapia Intensiva, Azienda Ospedaliera San Gerardo di Monza, Dipartimento di Medicina Sperimentale, Università degli Studi Milano-Bicocca, Milan, Italy.
Nicolò
N
Patroniti
Hadassah Medical Centre, Hadassah School of Public Health, The Hebrew University, Jerusalem, Israel.
Mario
M
Baras
Department of Anesthesiology and Critical Care Medicine, Hadassah Hebrew University Medical Centre, Jerusalem, Israel.
Charles L
CL
Sprung
D000368:Aged; D003657:Decision Making; D005260:Female; D006801:Humans; D007362:Intensive Care Units; D008297:Male; D008875:Middle Aged; D009026:Mortality; D010343:Patient Admission; D011336:Probability; D011446:Prospective Studies; D016079:Refusal to Treat; D014218:Triage