Intensivist Preferences for Patient Admission to ICU

When patients present to the emergency room and need admission, they are first evaluated by the physician. Patients who are stable but need admission are usually admitted to the general medical floor. Those who are unstable, very old, or very young or those with numerous comorbidities are usually admitted to the intensive care unit. The ICU is known for its special treatment and round the clock monitoring by ICU nurses that is typically not available on the general medical floors. 

Patients who are terminally ill or have limited life expectancy are usually not admitted to the ICU because the treatments usually do not benefit them and are more likely to cause more harm than good. However, there are many other patients who are borderline ill and have a few comorbidities. In such cases, physicians require a great deal of clinical acumen in deciding where to admit the patient. Sometimes physicians have to make immediate decisions because of the seriousness of the patient’s condition. However, empirically admitting all patients who are borderline ill to the ICU is not only expensive, but may also take away a bed from a seriously ill patient. 

In a new study, researchers from the United Kingdom investigated factors that played a role in the admission of patients to the ICU. They looked at both clinical and nonclinical factors, and performed an experiment where they presented senior intensive care physicians working in NHS hospitals with pairs of patient profiles and asked them to prioritise which would require admission to the critical care unit. Factors they included in the experiment included patient age, family perception of the illness, and severity of the primary complaint. 

What they noted was that the patient's age was the biggest determining factor for admission to the ICU. This was followed by the perception of the illness by the family and the severity of the main morbidity. It was also observed that physiological measures indicating the severity of the illness had a minor role in ICU admission. In fact, it was the overall ‘gestalt’ assessment by the clinician that factored in ICU admission

Besides advanced age, they also observed that younger patients, those with severe acute illness, good functional status, those in wards with reduced nursing, and family insistence also played a role in ICU admission. A factor in ICU admission was a general feeling (gestalt or holistic approach) of the admitting doctor about the patient’s illness. Mildly severe morbidity was associated with ICU admission, but patients with severe morbidity were less likely to be admitted.

The conclusion was that admission to the ICU in NHS hospitals depended on several factors, but overall it was dependent on patient age and the clinican's overall impression of the patient's illness. Physiological factors were rarely utilised for admission purpose, and there was little objectivity in the process of admission. Overall, study researchers feel that there is a lack of transparency in the decision-making process, which may lead to unequal care of sick patients. The conclusion was that more solid objective guidelines are needed to ensure that admission to the ICU is based on physiological information and not just gestalt evaluation.

Source: Critical Care Medicine

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