Outcomes of patients considered for, but not admitted to, the intensive care unit

Objective. The purpose of this study is to evaluate factors associated with decisions to reject patients from medical intensive care unit (MICU) admission and assess the outcome of these patients. Design: Prospective, observational cohort study. Setting: Large tertiary referral, teaching hospital. Patients. Consecutive patients evaluated for MICU admission but not admitted. Measurements. Patient characteristics and demographics, location of evaluation, clinical and laboratory data, major organ system dysfunction, 48-hr patient status, and 6-month mortality. Main Results: A total of 1,302 patients were admitted to the MICU, 353 patients were evaluated for the MICU but were not admitted, and 324. patients were used in analysis. Mean age was 68.6 +/- 17.1 yrs, and 57.7% were women. Hospice care was instituted during or immediately after evaluation in 8.3% (n = 27) of cases. MICU care was declined by the patient in 5.2% (n = 17) of evaluations. The mean Acute Physiology and Chronic Health Evaluation (APACHE) II score was 17.4 +/- 6.0. Factors associated with death at 6 months included age, APACHE 11 score, entering hospice, and patient choice to decline care. Of the patients considered too well to benefit, 9% were admitted to the MICU within 48 hrs and 35.5% died within 6 months; however, no deaths occurred within 48 hrs. Conclusions. Patients who are considered for critical care are at very high risk of mortality within 6 months. Given that no deaths occurred within 48 hrs and that only 9% needed intensive care unit admission within 48 hrs, the house staff's decision process is safe at this one institution.