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Mortality as a measure of lack of ICU availability


Patients who need intensive care but are not admitted to the ICU have a poor outcome, while demand for ICU beds exceeds supply. Patients dying outside the ICU might include those for whom ICU care has been refused, and as a result have had a poor outcome. Examination of patients dying outside the ICU could therefore reveal the extent to which ICU refusal is associated with subsequent mortality, and for which patients.


That a request for ICU admission has been made for a significant proportion of patients dying in non-ICU admission areas, and that access to ICU care for fatally ill patients is not equal for all hospital departments.


Over a 6-month period, demographic data were collected on all patients who died in the Hadassah Hebrew University Medical Center, Jerusalem, both in and out of the ICU. For those dying outside the ICU, the treating physicians were interviewed regarding do-not-resuscitate (DNR) status, requests for ICU admission, or the reasons why ICU admission was not requested.


Overall 366 patients died during the study, 244 (67%) outside ICUs and 122 (33%) within ICUs. Of the patients dying outside the ICU, a request for ICU admission was made and refused for only 18/244 (7%) patients. Of these, six (33%) were assigned a DNR order. Among the 226 patients for whom ICU was not requested, 71 (31%) were not DNR. The ICU was not requested for the following 106 reasons (more than one possible per patient): poor prognosis (42 [40%]), patient died suddenly or found dead in bed (33 [31%]), no indication (12 [11%]), severity of underlying disorders (9 [8%]), advanced age (4 [4%]) and others (6 [6%]). The treating physicians believed that ICU care could have been beneficial for 20/71 (18%) of these patients.

Among non-DNR patients dying outside the ICU, 67/71 (94%) were from medical wards and the remaining four (6%) patients from surgical wards, as compared with 69/122 (57%) medical and 53/122 (43%) surgical patients among those dying in the ICU (P < 0.0001). The mean age of the patients dying outside the ICU was 70 ± 18 years vs 63 ± 20 years for those dying in ICUs (P = 0.0153).


ICU care is requested for only a minority of patients dying on hospital wards, even when patients are not defined as DNR, and when the treating physicians believe that this care might be beneficial. Few surgical patients die outside the ICU (as compared with medical patients), while patients dying in ICUs are younger.

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Levin, P., Avidan, A., Nesher, T. et al. Mortality as a measure of lack of ICU availability. Crit Care 10 (Suppl 1), P431 (2006).

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