Extent and pattern of intensive care unit refusal in Tunisian 3rd line hospitals

Abstract

Background: Rationing in intensive care unit (ICU) beds is common and can leads to admission refusal. Understanding factors involved in triage practices is the first step towards an ethically optimal decision-making process.

Aim: To identify determinants and patients' characteristics associated with decisions to deny ICU admission.

Methods: This prospective observational study was conducted in AbderrahmeneMami Hospital's medical ICU, in Ariana, between 1st January and 31th December 2016. No predefined admission criteria were determined. All consecutive patients referred to ICU for admission during the study period were included. Two groups were defined GI: Admitted patients and GII: Refused patients. The reasons for refusal were categorized as follows: full unit, necessity of reorientation, patient too well to benefit, patient too sick to benefit and patient or family refusal.

Results: During the study period, ICU admission was requested for 1081 patients of whom 491 (45.4%) were refused. Logistic regression identified factors positively associated with ICU refusal. A surgical status (AOR 15,80 ; IC95% 1,34-186,17 ; p=0,028), was found to be the main factor, followed by cardiopulmonary arrest (AOR 5,91 ; IC 95% 2,54-13,76 ; p<0,001) and hematologic malignancies (AOR 2,82 ; IC 95% 1,32-6,02 ; p=0,007). In contrast, other factors were shown to be negatively associated with ICU refusal; it was essentially ICU admission requested from our hospital (AOR 0,06; IC 95% 0,04-0,08 ; p<0,001). Full unit was the predominant reason for refusal (76.2%).

Conclusion: Our study confirms that ICU refusal is common. It depends on both organizational and patient-related factors.