Log in | Register

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

Maha Louriz| Khalid Abidi| Mostafa Akkaoui| Naoufel Madani| Kamal Chater| Jihane Belayachi| Tarek Dendane| Amine Ali Zeggwagh| Redouane Abouqal
Original
Volume 38, Issue 5 / May , 2012

Pages 830 - 837

Abstract

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 (85, 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; p < 0.001), neurological disease (OR 4.05; 95% CI 1.33–12.28; p = 0.01) and lack of available ICU beds (OR 6.26; 95% CI 4.14–9.46; p < 0.001). Hospital mortality was 33.3% (37/110) for immediately admitted patients, 43.8% (64/146) for patients admitted later and 49.3% (70/142) for never admitted patients.

Conclusion

Refusal of ICU admission was correlated with the severity of acute illness, lack of ICU beds and reasons for admission request. Further efforts are needed to define which patients are most likely to benefit from ICU admission and to improve the accuracy of data on ICU refusal rates.

Keywords

TriageICUAdmissionBed capacityMortality

References

  1. Ip M, Galligan T, Koenig B, Raffin TA (1998) Ethical decision-making in critical care in Hong Kong. Crit Care Med 26:447–451
    • View reference on PubMed
    • View reference on publisher's website
  2. Scheinkestel CD (1996) The evolution of the intensivist: from health care provider to economic rationalist and ethicist. Med J Aust 164:310–312
    • View reference on PubMed
  3. Vincent JL (1996) European attitudes towards ethical problems in intensive care medicine/results of an ethical questionnaire. Intensive Care Med 16:256–264
  4. Strauss MJ, LoGerfo JP, Yeltatzie JA, Temkin N, Hudson LD (1986) Rationing of intensive care unit services. Aneveryday occurrence. JAMA 255:1143–1146
    • View reference on PubMed
    • View reference on publisher's website
  5. Miller DH (1994) The rationing of intensive care. Crit Care Clin 10:135–143
    • View reference on PubMed
  6. Sprung CL, Geber D, Eidelman LA, Baras M, Pizov R, Nimrod A, Oppenheim A, Epstein L, Cotev S (1999) Evaluation of triage decisions for intensive care admission. Crit Care Med 27:1073–1079
    • View reference on PubMed
    • View reference on publisher's website
  7. Society of Critical Care Medicine Ethics Committee (1994) Attitudes of critical care medicine professionals concerning distribution of intensive care resources. Crit Care Med 22:358–362
  8. Lyons RA, Wareham K, Hutchings HA, Major E, Ferguson B (2000) Population requirement for adult critical-care beds: a prospective quantitative and qualitative study. Lancet 355:595–598
    • View reference on PubMed
    • View reference on publisher's website
  9. Task Force of the Society of Critical Care Medicine SCCM (1999) Guidelines for intensive care unit admission, discharge, and triage. Crit Care Med 27:633–638
    • View reference on publisher's website
  10. Bone RC, McElwee NE, Eubanks DH, Gluck EH (1993) Analysis of indications for intensive care unit admission: clinical efficiency assessment project: American College of Physicians. Chest 104:1806–1811
    • View reference on PubMed
    • View reference on publisher's website
  11. Consensus Development Panel (1983) Critical care medicine. JAMA 250:798–804
    • View reference on publisher's website
  12. Connors AF Jr, Speroff T, Dawson NV, Thomas C, Harrell FE Jr, Wagner D, Desbiens N, Goldman L, Wu AW, Califf RM, Fulkerson WJ Jr, Vidaillet H, Broste S, Bellamy P, Lynn J, Knaus WA (1996) The effectiveness of right heart catheterization in the initial care of critically ill patients. JAMA 276:889–897
    • View reference on PubMed
    • View reference on publisher's website
  13. Society of Critical Care Medicine Ethics Committee (1994) Consensus statement on the triage of critically ill patients. JAMA 271:1200–1203
    • View reference on publisher's website
  14. World Health Organization (2004–2007) Country cooperation strategy for WHO and Morocco 2004–2007. http://www.who.int/countries/en/cooperation_strategy_mar_en.pdf
  15. McCabe WR, Jackson GG (1962) Gram negative bacteremia: etiology and ecology. Arch Intern Med 110:847–855
    • View reference on publisher's website
  16. Lemeshow S, Teres D, Klar J, Spitz Avrunin J, Gehlbach SH, Rapoport J (1993) Mortality probability models (MPM II) based on an international cohort of intensive care unit patients. JAMA 270:2478–2486
    • View reference on PubMed
    • View reference on publisher's website
  17. Joynt GM, Gomersall CD, Tan P, Lee A, Ai Yu, Cheng C, Lai Yi Wong E (2001) Prospective evaluation of patients refused admission to intensive care unit: triage, futility and outcome. Intensive Care Med 27:1459–1465
  18. Garrouste-Orgeas M, Montuclard L, Timsit JF, Reignier J, Desmettre T, Karoubi P, Moreau D, Montesino L, Duguet A, Boussat S, Ede C, Monseau Y, Paule T, Misset B, Carlet J, French ADMISSIONREA Study Group (2005) Predictors of intensive care unit refusal in French intensive care units: a multiple-center study. Crit Care Med 33:750–755
    • View reference on PubMed
    • View reference on publisher's website
  19. Reignier J, Dumont R, Katsahian S, Martin-Lefevre L, Renard B, Fiancette M, Lebert C, Clementi E, Bontemps F (2008) Patient-related factors and circumstances surrounding decisions to forego life-sustaining treatment, including intensive care unit admission refusal. Crit Care Med 36:2076–2083
    • View reference on PubMed
    • View reference on publisher's website
  20. Azoulay E, Pochard F, Chevret S, Vinsonneau C, Garrouste M, Cohen Y (2001) Compliance with triage to intensive care recommendations. Crit Care Med 29:2132–2136
    • View reference on PubMed
    • View reference on publisher's website
  21. Boumendil A, Somme D, Garrouste-Orgeas M, Guidet B (2007) Should elderly patients be admitted to the intensive care unit? Intensive Care Med 33:1252–1262
  22. Metcalfe MA, Slogget A, McPherson K (1997) Mortality among appropriately referred patients refused admission to intensive-care units. Lancet 350:7–11
    • View reference on PubMed
    • View reference on publisher's website
  23. Frisho-Lima P, Gurman G, Schapira A, Porath A (1994) Rationing critical care-what happens to patients who are not admitted? Theor Surg 9:208–211
    • View reference on PubMed
  24. Garrouste-Orgeas M, Montuclard L, Timsit JF, Misset B, Christias M, Carlet J (2003) Triaging patients to the CIU: a pilot study of factors influencing admission decision and outcome. Intensive Care Med 29:774–781
    • View reference on PubMed
  25. Singer DE, Carr PL, Mulley AG, Thibault GE (1983) Rationing intensive care-physician responses to a resource shortage. N Engl J Med 309:1155–1160
    • View reference on PubMed
    • View reference on publisher's website
  26. Sinuff T, Kahnamoui K, Cook DJ, Luce JM, Levy MM, Ethics Values, Rationing in Critical Care Task Force (2004) Rationing critical care beds: a systematic review. Crit Care Med 32:1588–1597
    • View reference on PubMed
    • View reference on publisher's website
  27. Iapichino G, Corbella D, Minelli C, Mills GH, Artigas A, Edbooke DL, Pezzi A, Kesecioglu J, Patroniti N, Baras M, Sprung CL (2010) Reasons for refusal of admission to intensive care and in impact on mortality. Intensive Care Med 36:1772–1779
  28. Nouira S, Roupie E, El Atrouss S, Durand-Zaleski I, Brun-Buisson C, Lemaire F, Abroug F (1998) Intensive care use in a developing country: a comparison between a Tunisian and French Unit. Intensive Care Med 24:1144–1151
  29. Nouira S, Belghith M, Elatrous S, Jaafoura M, Ellouzi M, Boujdaria R, Gahbiche M, Bouchoucha S, Abroug F (1998) Predictive value of severity scoring systems: comparison of four models in Tunisia adult intensive care units. Crit Care Med 26:852–859
    • View reference on PubMed
    • View reference on publisher's website
  30. Topeli A, Laghui F, Tobin M (2005) Effect of closed unit policy and appointing an intensivist in a developing country. Crit Care Med 33:299–306
    • View reference on PubMed
    • View reference on publisher's website
  31. Parikh CR, Kamad DR (1999) Quality, cost and outcome of intensive care in a public hospital in Bombay, India. Crit Care Med 27:1754–1759
    • View reference on PubMed
    • View reference on publisher's website
  32. Abidi K, Belayachi J, Derras Y, Khayari ME, Dendane T, Madani N, Khoudri I, Zeggwagh AA, Abouqal R (2011) Eosinopenia, an early marker of increased mortality in critically ill medical patients. Intensive Care Med 37:1136–1142
  33. Akkaoui M, Abidi K, Belayachi G et al (2009) Rate and modality of withdrawing and withholding of life-sustaining therapy in Moroccan medical intensive care Unit (Abstract). SRLF

Sign In

Connect with ICM

Top 5 Articles Editors Picks Supplement