Factors Associated with Intensive Care Unit Admission Refusal
Babatunde Osinaike, Tosin Olusanya
Department of Anesthesia, University of Ibadan/University College Hospital, Ibadan, Oyo State, Nigeria
Dr. Babatunde Osinaike, PMB 5116, Dugbe, Ibadan. Email: email@example.com
Background: The need for intensive care exceeds its availability most times because resources are limited. Our objectives were to determine the incidence of admission refusal and factors associated with such in our Intensive Care Unit (ICU). Methods: The following information was obtained from patients referred to our ICU over a 6-week period: age, gender, date and time of referral, source of referral, reason for referral, whether ICU was full or not full at the time of referral, and modified early warning score (MEWS). Others included; whether admitted or not, and if not admitted, reasons for admission refusal. Binomial logistic regression analysis was used to determine predictors of ICU admission refusal. Results: Patients admitted and those denied admission were 37(50.7%) and 36(49.3%) respectively. Following univariate analysis, there were no statistical differences in the age and MEWS of patients in the admitted and not admitted groups respectively. Refusal was highest for sepsis (80%) and respiratory failure (71.4%) and lowest for severe head injury (18.2%), no difference was found in the MEWS for patients with sepsis and those with severe head injury. Lack of ICU bed was the only independent predictor of ICU admission refusal. Conclusions: The crude ICU admission refusal rate was 49.3% and unavailability of ICU bed independently predicted ICU admission refusal. To ensure reduction in ICU admission refusals, the ratio of ICU beds over the population must be appropriate.
Key words: ICU, Admission refusal, Bed availability.
The Intensive Care Unit (ICU) remains a critical part of efficient health care delivery. Despite the high cost for critical care services, the need for intensive care often exceeds its availability most times because of limited resources (1, 2). Sometimes, request for admission into the ICU are turned down because of many patientrelated or organizational factors. Some studies have identified; older age, diagnosis, presence of comorbidities, and triage by a senior intensivist as predictors of admission refusal. Bed unavailability was a strong factor in these studies. (3, 4) The aim of this study was to determine the incidence and factors associated with ICU admission refusal.
This was a prospective observational study conducted in the 12-bed general ICU of the University College Hospital, Ibadan between February and April 2015 following institutional research ethics approval. All referrals for ICU admission were collated daily and the research assistant then visited the ICU or the Emergency Department the following morning to obtain necessary information from the ICU chart or case notes for referred patients. The following data were prospectively recorded; Age, gender, date and time of referral, source of referral, reason for referral, number of beds available in the ICU at the time of referral, modified early warning score (MEWS), whether admitted or not, and if not admitted, reasons for admission refusal. MEWS was employed because it’s easy to assess, and increasing score is said to correlate increased likelihood of critical care admission (5). All requests for ICU admission coming from each department within the hospital were included. Postoperative patients for elective ICU admissions were excluded. Binomial logistic regression analysis was used to determine predictors of admission refusal. A pvalue of < 0.05 was considered significant.
Ninety-nine referrals were received during the study period; however due to missing information only data from 73 patients were included in the analysis. Two weeks during the period of study, only six out of twelve beds were available in the ICU because of routine fumigation exercises. The number of patients admitted and those denied admission were 37(50.7%) and 36(49.3%) respectively. Following univariate analysis, there was no statistical difference in the age (37.65±18.48 years vs. 39.63±26.52 years) and MEWS (5.76±1.92 vs.5.94±1.51) of patients in the admitted and not admitted group respectively (p=0.71 and p=0.65).
Male gender (75.7 vs. 50.0) and referrals from the Emergency department (78.4 vs. 50.0) were significantly higher in the admitted group compared to those not admitted (p=0.02 and p=0.01) (Table 1). Refusal was highest for sepsis (80%) and lowest for severe head injury (SHI) (18.2%). No difference was found in the MEWS for patients with sepsis (6.60±1.35) and SHI (6.09±1.41) (p=0.35) (Table 2). The commonest reason for admission refusal was unavailability of ICU beds (81%). Other reasons included, 5% patient too well to require ICU admission, 5% patient demise, 3% no available patient monitor, 3% family refusal and 3% unavailability of mechanical ventilator. Logistic regression revealed