Characteristics and Outcomes of Patients Referred but Declined for ICU Admission in a Resource-Limited Setting in South Africa

OBJECTIVES: ICU beds are a limited resource and assessing net benefit from ICU admission remains incompletely understood. We sought to examine characteristics and outcomes of patients referred but declined for ICU admission, stratified by clinician-perceived likelihood of ICU benefit. DESIGN: Descriptive, retrospective cohort study. SETTING: Two public hospitals in the KwaZulu-Natal Department of Health, South Africa, from January 2022 to June 2022. PATIENTS: Adult ICU-referred patients classified into four triage cohorts by clinician-assessed acuity and ICU triage status: ICU admissions; high-acuity capacity-declined ICU referrals; high-acuity prognosis-declined ICU referrals; and low-acuity prognosis-declined ICU referrals. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: We report descriptive statistics of ICU-referred patient characteristics stratified by triage cohorts and mortal status. Among 866 ICU referrals, 469 patients (54.2%) were admitted, and 397 patients (45.8%) were declined for ICU admission. ICU admissions had an observed all-cause 30-day hospital mortality of 27.7%. Among declined ICU referrals with nonmissing triage priority scores ( n = 327), 250 patients (76.5%) were declined ICU admission for prognosis reasons, and 77 patients (23.5%) were declined for capacity reasons. Seventy-seven (9.7% of ICU referrals) high-acuity capacity-declined ICU referrals (“appropriate patient; no bed capacity; not admitted”) had a 26.0% mortality (74.0% survival), 111 (13.9%) high-acuity prognosis-declined ICU referrals (“too sick; not admitted”) had a 53.2% mortality (46.8% survival), and 139 (17.5%) low-acuity prognosis-declined ICU referrals (“too well; not admitted”) had a 7.2% mortality. Declined ICU referrals were less likely surgical/trauma patients and more likely medical patients coming from wards and emergency departments. CONCLUSIONS: In one sampling in the South African public healthcare system, many patients are referred but declined for ICU admission due to perceptions of being both “too well” or “too sick” to benefit and due to bed capacity, with a proportion of such patients experiencing potential clinical deviations from triage-expected trajectories.