MORTALITY AMONG APPROPRIATELY REFERRED PATIENTS REFUSED ADMISSION TO INTENSIVE-CARE UNITS

Background The provision of intensive care is a perplexing issue for c linicians and the public. Concerns about the apparent lack of beds and the appropriateness of the patients admitted are tempered by the high cost of providing this service. As part of a study commissioned by th e UK Department of Health, we tested the hypothesis that there is exce ss mortality among patients who are refused admission to intensive-car e units. Methods All referrals to six intensive-care units with differ ent numbers of beds were monitored during a 3-month period. Data on mo rtality 90 days after first referral were obtained from family physici ans for all patients known to be alive at hospital discharge. We adjus ted, where possible, for confounding, including for age, sex, appropri ateness of referral, disease severity, surgery and emergency categorie s, and bed provision. We did multivariate analysis by multiple logisti c regression to compare the adjusted 90-day mortality rates for patien ts who were refused admission and for those admitted. Findings 480 pat ients were admitted and 165 were refused admission. 90 days after refe rral there had been 178 (37%) deaths among the admitted group and 75 ( 46%) among the refused group. After multivariate adjustment, 113 patie nts appropriately referred for intensive care but refused admission to their first-choice intensive-care unit had a relative risk of death o f 1.6 (95% CI 10-2.5), compared with the group of appropriately admitt ed cases with medium APACHE II scores for disease severity. Age, the a ssessed need for treatment or monitoring interventions, and emergency status also contributed to differences in mortality among all referral s. Bed provision did not contribute significantly to excess mortality. Interpretation Although this study is observational and case-mix adju stment is incomplete, we found a higher rate of attributable mortality in patients who were refused intensive care, particularly for emergen cy cases. We question whether the provision of more beds alone would b e a solution and conclude that there is an urgent need for more approp riate admission and discharge criteria.