Determinants and outcomes associated with decisions to deny intensive care unit admission in Tunisian ICU

Abstract

Introductionintensive care unit (ICU) beds are a scarce resource, and admissions may require prioritization when demand exceeds supply. However, there are few data regarding both outcomes of admitted patients to intensive care unit (ICU) in comparison with outcomes of not admitted patients. The aim of this study was to assess reasons and factors associated to refusal of admission to ICU as well as the impact on mortality at 28 days and patients' outcomes.MethodsSingle-center, cross-sectional descriptive study conducted in 8-bed Medical ICU at a Tunisian University hospital. All consecutive adult patients referred for admission to ICU during 6 months were included. We collected demographic data, ICU admission/refusal reasons, co-morbidity and diagnosis at time of admission, mortality probability model (MPMII0) score, day and time of admission, request for admission and mortality at 28 days.Results327 patients were evaluated for ICU admission and 260 were refused to ICU (79.5%). Patients refused because of unavailability of beds represented 50% and patients considered “too sick to benefit” represented 22%. Multivariate analysis showed that the presence of acute respiratory failure and request by direct contact in the unit were independently associated to admission to ICU (OR: 0.15; 95% CI: 0.07-0.31 and OR: 0.16; 95% CI: 0.08-0.31, respectively). Higher mortality rates were shown in patients “too sick to benefit” (80.7%) and unavailable beds (26.56%).ConclusionRefusal of ICU admission was correlated with the severity of acute illness, lack of ICU beds and reasons for admission request. ICU clinicians should evaluate their triage decisions and, if possible, routinely solicit patient preferences during medical emergencies, taking steps to ensure that ICU admission decisions are in line with the goals of the patient. Ultimately, these efforts will help ensure that scarce ICU resources are used most effectively and efficiently.

Challenges of the patient transition process from the intensive care unit: a qualitative study

“…The problem of inadequate communication for information exchange among the care providers is the potential source of mortality and morbidity in patients. These communication problems are more common in the transition hand-off between two places when the responsibility of the patient shifts between the members of the care team [ 36 ] and if the communication method is not clear and consistent. A basic analysis of these failures showed that the lack of a standard protocol for transition from the ICU to a ward is a contributing factor to the potential risks of harm to the patient [ 37 ].…”

Is Modified Early Warning Score associated with clinical outcomes of patients admitted to a university internal medicine ward?

“…Such findings have important implications for bed turnover and may change some physicians’ habits, such as forgoing requests for ICU bed requests and treating critically ill patients in the ward itself due to the low availability of ICU beds. Bouneb et al (2018) reported that ICU admissions may require prioritization when demand exceeds supply. In their study, they observed that the lack of available beds in the ICU led to the refusal of 50% of requests for beds and the assessment of 22% of patients as “too sick to benefit.”…”

“…The MEWS is commonly used in hospital settings, including the emergency department (Johnson et al, 2017; Trajkovska et al, 2019; Xie et al, 2018) and wards (Churpek et al, 2015; Van Galen et al, 2016; Ludikhuize et al, 2015; Mathukia et al, 2015). The use of MEWS scores has been explored both in out‐of‐hospital settings (Jouffroy et al, 2018) and in the hospital before transfers between units (Salottolo et al, 2017), and in intensive care units (ICU) (Bouneb et al, 2018). In general, studies have included adults, and some have focused on the elderly (Churpek et al, 2015).…”

Identificação da piora do quadro clínico do paciente internado na enfermaria

“…Observou-se mortalidade em 48h de 52% 39 em pacientes com perfil de gravidade similar ao do presente estudo. Na experiência presente 11 pacientes foram intubados ainda na enfermaria, por agravamento de suas condições, com pedido de vaga em UTI para apenas 7 deles.…”

“…No estudo de Bouneb 39 , 50% dos casos de vaga recusada ocorreu por falta de disponibilidade de leitos, sendo a taxa de recusa de 79% para as solicitações. Sabese que o ambiente de UTI requer maior responsabilidade da enfermeira e demanda mais emocional, física e mental 40 .…”