Unsuitable for the Intensive Care Unit: What Happens Next?

Abstract

Context:

In recent years numbers of referrals to intensive care units (ICU) throughout the United Kingdom has been increasing. A number of referrals to the ICU are considered to be inappropriate for a variety of reasons, including those patients who are felt to be either too well for admission, or have comorbidities making survival unlikely and aggressive interventions unsuitable.

Objectives:

This study aims to examine the outcomes and symptoms in those patients who are unsuitable for admission to ICU. By looking at this population we hope to ascertain if this is an at-risk group in terms of symptomatic or care needs at the end of life.

Methods:

This was as an observational prospective study with the sample population identified via the ICU referrals process. All patients referred to the ICU for admission but deemed unsuitable were recorded and followed up by researchers on the wards.

Results:

Fifty patients were identified between January and April 2009. Outcomes at one week were split between “death” (34%), “discharge” (24%), and ongoing illness/rehabilitation (40%). Levels of comorbidity were high, with a corresponding prevalence of severe breathlessness in all outcome groups.

Conclusion:

The results suggest there are small numbers of patients with uncontrolled symptoms who could benefit from specialist input from the palliative care team. The identification of the imminently dying should facilitate appropriate communication of this by clinical staff and allow the relevant social, psychological, and spiritual preparations for death that are the hallmark of good care of the dying.

Introduction

In recent years numbers of referrals to intensive care units (ICU) throughout the United Kingdom have been increasing,¹ with growing pressure on a small number of available beds. Those patients who are referred for intensive care are frequently critically unwell, with a significant mortality of approximately 30% recorded in U.K. units in those admitted for support.² A number of referrals to the ICU are considered to be inappropriate for a variety of reasons, including those patients who are felt to be either too well for admission, or have comorbidities making survival unlikely and aggressive interventions unsuitable.^3,4 The identification of these patients who are unsuitable for admission is a complex and controversial problem,^3,5–7 but both appropriate use of resources and the potential negative outcomes of admission to the ICU^6,7 make close review and selection essential.

There have been a small number of non-U.K. studies examining mortality in those patient groups deemed unsuitable for ICUs^3,4,8 demonstrating that “refusal” of admission is common and that the mortality in these patients high. Despite this there has been no research looking at the reasons for referral and subsequent decisions regarding unsuitability or examination of symptom load in this patient group. Additionally, in view of the high mortality known in this population, there is no research in the palliative care literature examining care needs for this group.

Glasgow Royal Infirmary (GRI) is a large teaching hospital based in the northeast of the city with over 1000 beds. The GRI ICU has 9 funded beds and accommodated 426 admissions during 2009. There is an established Hospital Specialist Palliative Care Team (HSPCT) in GRI, comprising one consultant in palliative medicine and two specialist nurses. Telephone referrals are accepted from ward teams, and rapid response cover is available 9:00 am to 5:00 pm Monday to Friday, with a telephone advice service after hours. Prior to this study the team had little direct involvement with ICU inpatients or referrals.

Aims

This observational prospective study examined the outcomes and symptoms in those patients who were deemed unsuitable for admission to GRI ICU, either due to being too well to require ICU intervention, or so unwell that escalation of support was unlikely to alter outcome. By looking at this population we aimed to ascertain if this is an at-risk group in terms of symptomatic or care needs at the end of life in which specialist palliative care teams should become involved, as well as examining how this may best be implemented.

Methods

This was an observational prospective study with the sample population identified via the ICU referrals process. Ethical approval was sought from the Glasgow and Clyde Ethics and Research Committee but was not required. All patients referred to GRI ICU for admission but deemed unsuitable for any reason were recorded by the team and documented in the department. Each day the referrals from the previous 24 hours were reviewed on the wards by palliative medicine researchers. care of all patients remained with the referring team, and palliative care input was provided only if specifically requested.

Demographic information (age, gender, diagnosis) and data on patient's symptoms of pain, nausea, and breathlessness were recorded using an abbreviated Support Team Assessment Schedule (STAS).⁹ The STAS document is a reliable, validated, widely used tool that allows recording of multiple areas of need in a nonintrusive and practical manner.^9,10 A STAS score of 0–4 was recorded at four time points (24, 48, 72 hours, and 1 week) with scores based on case note entries by referring team, or direct observation by researchers (0 = symptom not present, 1 = occasional symptom, 2 = moderate distress, 3 = severe symptom, 4 = symptom very severe). Pain, nausea, and breathlessness were selected from the full STAS as likely to be the most problematic and easily identifiable. Further data on progress and outcome were drawn from case notes and drug kardex and recorded on an audit proforma aiming to include 50 consecutive patients. Final information on comorbidities identified at admission, as well as use of End of Life Care Pathways (EOLP) and do-not-attempt resuscitation (DNAR) status were also documented. Data collected were analyzed with SPSS (SPSS Inc., Chicago, IL) using descriptive techniques.

Results

Referrals

Fifty patients were deemed unsuitable for admission to ICUs between January and April 2009, with approximately 100 admissions accepted over this same time period. The age range of patients was 24 to 86 with a mean of 62 years. Twenty-eight of the 50 patients were female. There were a variety of diagnoses at presentation to hospital (Table 1) with the majority being respiratory illnesses (20 patients, 40%). A high level of comorbidities, particularly chronic obstructive pulmonary disease (COPD; 26%), cardiac disease (38%) and alcohol-related illness (22%) were recorded and frequently coexisted. Only 6 (12%) of patients were recorded as having no comorbidities.

Table 1.

Diagnosis at Presentation

Diagnosis	Number	Diagnosis	Number
Exacerbation of COPD	8	Fractured neck or femur	1
Pneumonia SP tract infection	12	Hypothermia	1
Alcoholic liver disease	1	Pulmonary edema	1
Myocardial infarction	1	Post-op complications	3
Overdose	3	Intracerebral bleed/stroke	1
Bowel perforation	3	Epilepsy	2
Pancreatitis	3	Hypoxic brain injury	1
Sepsis (nonspecific)	3	Head injury	1
Bowel ischaemia	2	Incarcerated hernia	1
Asthma	2

COPD, chronic obstructive pulmonary disease.

The reasons for ICU referral were in keeping with diagnosis as most frequently being for respiratory support (20 patients, 40%), although overwhelming sepsis requiring inotropic support was also common (14 patients, 28%; Fig. 1).

FIG. 1.

Reason for ICU referral

Patients were most frequently deemed unsuitable for admission as they were felt to be “too well” at time of referral (24 patients, 48%). The second most common reason for unsuitability was excessive comorbidities (16 patients, 32%) with an additional 9 (18%) explicitly identified by the ICU team as suffering likely imminently fatal insults even if ICU support was provided, including those without preexisting illness. One patient was referred for assessment for ICU after planned emergency surgery, which was deemed an inappropriate referral, and surgery proceeded without need for ICU care (Fig. 2).

FIG. 2.

Reason unsuitable for intensive care unit (ICU).

Symptoms

Pain

For most patients, pain was not a major symptom. At 24 hours postreferral, 36 of 44 (82%) patients with data recorded had a STAS score of 2 or less, with 26 patients (59%) having no pain at all. It is notable however that 8 (18%) patients at this stage had pain scores of 3 or 4, denoting significant symptom scores (Fig. 3). This pattern is repeated though all time points, with a small number of patients continuing to suffer with severe pain up to a week after referral (4%–8%), with the majority remaining relatively pain free.

FIG. 3.

Pain Support Team Assessment Schedule (STAS) scores.

Breathlessness

As would be expected with the predominant recorded diagnosis and co-morbidities, breathlessness was frequently recorded as problematic in our study population. At 24 hours postreferral fewer than one third (28%) of patients recorded no breathlessness, with 17 (34%) returning STAS scores of 3 or 4 (Fig. 4). While severity scores decreased with time, it remained a minority of patients at all time points that were symptom free, and as with pain a small number suffered persistent severe symptoms (8% at 72 hours).

FIG. 4.

Breathlessness Support Team Assessment Schedule (STAS) scores.

Nausea

Nausea was noted infrequently. At 24 hours 66% of patients scored a STAS score of zero, and at no point did any of our sample population record very severe (STAS 4) symptoms (Fig. 5). A small number of patients did persist with moderate or severe nausea up to 72 hours postreferral (score 2–3; 3 patients) but this seemed to be less problematic than the other symptoms documented.

FIG. 5.

Nausea Support Team Assessment Schedule (STAS) scores.

Outcomes

A number of patients remained in hospital at 1 week postreferral, 17 patients (34%) with ongoing illness and 4 patients (8%) for rehabilitation (Fig. 6). A significant number of patients were discharged home, (12 patients, 24%) and 17 patients died (34%). Of those who died, the majority (59%) occurred within 24 hours of ICU referral and before full symptom data could be collected. All other deaths occurred within 1 week of referral. Fifteen patients had DNAR documentation in place, and cardiopulmonary resuscitation (CPR) was attempted in the remaining 2 patients, but EOLP were not used in any cases. HSPCT were asked to be involved in just 2 cases (4%) both of whom had underlying malignancy.

FIG. 6.

Outcomes at 1 week.

Nine of the 17 deaths had been identified as having nonsurvivable insults at ICU referral, 7 as having excess comorbidities making ICU inappropriate, and just 1 identified as being “too well”—although on review this death was attributed to a new cardiac event post-ICU review (Fig. 7). Of those deemed “too well,” 96% were alive at 1 week (Fig. 8).

FIG. 7.

Comorbidities outcomes.

FIG. 8.

“Too well” outcomes.

Discussion

This study provides one of the first assessments of patients deemed unsuitable for admission to the ICU, specifically examining reason for nonadmission as well as an assessment of the symptom burden and outcomes in this population.

In terms of “unsuitable” referrals to the ICU team, there were large percentages that were considered too well or had such severe comorbidities that an ICU admission was felt inappropriate. Establishing who should make these decisions and referrals is difficult, but it could be argued that the ward teams should be identifying those clearly unsuitable for more invasive levels of care, selecting those patients for whom a more palliative care approach would be appropriate at an earlier stage. On occasion it has been felt that ward referrals become a “knee-jerk” reaction to patients failing on the wards, with ICU referrals made “just in case.”¹¹ Clearly this is not a good use of a specialist team, and it may be felt more consistent senior involvement prior to these referrals would be appropriate, as supported by ICU literature¹² and national guidance.¹³

The prevalence of “breathlessness” as the major symptom seen was not surprising. GRI is a hospital with significant surrounding areas of low socioeconomic status and associated high levels of smoking, COPD and other comorbidities that contribute to this symptom load. As such, a large number of referrals were specifically of a respiratory nature, and those that were not often had COPD as a comorbidity. COPD is known to produce significant symptoms,¹⁴ with ongoing work within palliative medicine as to how best to manage this patient group most effectively.¹⁵ Lower levels of pain and nausea perhaps reflect the nonmalignant nature of this patient group, but the persistence of severe, uncontrolled symptoms in small numbers is concerning and may require further research.

From this study it would seem the ICU team are accurate when predicting both those likely to die (100% specificity), as well as those likely to survive (96% specificity) without ICU input. It was not possible to specifically link high STAS scores with high mortality in this study population, making referral to HSPCT based on symptom scores alone difficult. The data would suggest that there may be a role for increased awareness and understanding of symptom management in a more generalised population. HSPCT cannot be involved with all patients with breathlessness without significant service expansion, but a focus on education and a better understanding of its pathophysiology and potential management among general surgeons and physicians may be of importance. Raising awareness of the HSPCT in respect to nonmalignant patients may help this also. At the same time, prompt referrals are required for those most gravely unwell with high symptom loads, as time may be short and rapid action required.

Locally and in the literature^6,7,16–18 there is a growing interest from the ICU community surrounding end-of-life care (EOLC) and palliative care. This work has seen closer links between the GRI HSPCT and ICU teams, with ongoing work to establish a more formalized referral pathway for those who may benefit from specialist palliative care input, as well as the development of further cross-specialty research and audit plans for the future.

Limitations

As this was an observational study, symptom scores were open to interpretation by the researchers. Where possible and appropriate, scores were obtained direct from the patient, but frequently this was not possible and end-of-bed assessment or case note review was required. Clearly this has limitations, but as both data collectors regularly utilize STAS scoring systems and assess symptoms as part of daily practice, this bias was felt to be minimized. There was concern that not all referred “unsuitable” patients would be documented, but rigorous review by the ICU team reduced this bias and it was felt the group was fully representative. Early death (within 24 hours) made assessment of symptoms in this most gravely unwell group difficult to assess, although where possible information was taken from notes. Finally, there was concern that ICU bed availability would alter who were accepted for admission—after discussion with the ICU team, beds were available, or could have been made available, for any patient that was deemed suitable during the study period.

Conclusions

This study suggests that the local ICU team are sensitive and specific at identifying those patients who are either too well for admission and likely to survive, as well as selecting those patients for whom intensive care is unlikely to be of benefit as their insult is presumed fatal. The results also suggest there are small numbers of patients with uncontrolled symptoms who could benefit from specialist input from the palliative care team, but it is not possible to correlate severe symptoms scores with poor outcomes/death based on these results.

The literature suggests there might be potential for fruitful collaboration between palliative medicine and ICUs.^16–18 We would suggest those patients whom ICU identifies as unlikely to survive should be carefully assessed for symptom issues and a prompt referral to the palliative care team made. In addition, this identification of the imminently dying should facilitate appropriate communication of this by clinical staff and allow the relevant social, psychological and spiritual preparations for death that are the hallmark of good care of the dying.

Footnotes

Author Disclosure Statement

No competing financial interests exist.

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