Prospective evaluation of patients refused admission to an intensive care unit: Triage, futility and outcome

Abstract

Objectives: To evaluate factors associated with decisions to refuse ICU admission and to assess the outcome of refused patients. Design and setting: Prospective, descriptive evaluation in a multi-disciplinary intensive care unit, university referral hospital. Patients and participants: All adult emergency referrals over a 7-month period. Interventions: 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. Measurements and 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.