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BJA Advance Access published online on November 25, 2005
British Journal of Anaesthesia, doi:10.1093/bja/aei276
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© The Board of Management and Trustees of the British Journal of Anaesthesia 2005. All rights reserved. For Permissions, please e-mail: journals.permissions@oxfordjournals.org
Accepted September 12, 2005

Clinical Investigation

Physicians' perceptions and attitudes regarding inappropriate admissions and resource allocation in the intensive care setting{dagger}

A. Giannini 1 * and D. Consonni 2

1 Paediatric Intensive Care Unit, Ospedale Maggiore Policlinico, Mangiagalli e Regina Elena, Via della Commenda 9, 20122 Milano, Italy
2 Unit of Epidemiology, Ospedale Maggiore Policlinico, Mangiagalli e Regina Elena, Via San Barnaba 8, 20122 Milano, Italy

* To whom correspondence should be addressed.
A. Giannini, E-mail: a.giannini{at}policlinico.mi.it


  Abstract

Background. Physicians' perceptions regarding intensive care unit (ICU) resource allocation and the problem of inappropriate admissions are unknown.

Methods. We carried out an anonymous, self-administered questionnaire survey to assess the perceptions and attitudes of ICU physicians at all 20 ICUs in Milan, Italy, regarding inappropriate admissions and resource allocation.

Results. Eighty-seven percent (225/259) of physicians responded. Inappropriate admissions were acknowledged by 86% of respondents. The reasons given were clinical doubt (33%); limited decision time (32%); assessment error (25%); pressure from superiors (13%), referring clinician (11%) or family (5%); threat of legal action (5%); and an economically advantageous ‘Diagnosis Related Group’ (1%). Respondents reported being pressurized to make more ‘productive’ use of ICU beds by Unit heads (frequently 16%), hospital management (frequently 10%) and colleagues (frequently 4%). Five percent reported refusing appropriate admissions following ‘indications’ not to admit financially disadvantageous cases. Admissions after elective surgery prioritized patients from profitable surgical departments: frequently for 6% of respondents and occasionally for 15%. Sixty-seven percent said they frequently received requests for appropriate admissions when no beds were available. This was considered sufficient reason to withdraw treatment from patients with lower survival probability (sometimes 21%) or for whom nothing more could be done (sometimes 51%, frequently 11%).

Conclusions. Inappropriate ICU admissions were perceived as a common event but were mainly attributed to difficulties in assessing suitability. Physicians were aware that their decisions were often influenced by factors other than medical necessity. Economic influences were perceived as limited but not negligible. Decisions to forgo treatment could be influenced by the need to admit other patients.

Keywords: end-of-life decisions; ethics; intensive care; patient admission; resource allocation.
{dagger}Presented, in part, at the Joint Meeting of the European Society of Anaesthesiologists and European Academy of Anaesthesiology, Lisbon, Portugal, June 5-8, 2004, and published in abstract form in Eur J Anaesthesiol 2004; 21 (Suppl 32): A712.
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