While a full ICU is often implicated for delays,8–12 other reasons such as procedural standards and staffing issues,9 as well as the diagnosis and prognosis of the patient,8 13 have been cited as reasons for refusal of admission. Inability to recognise the severity

of the patient’s condition has likewise been cited example as a cause of delays in ICU admission.14 15 A study which compared direct and indirect admissions noted that patients whose admission to the ICU were delayed were more likely to have been initially assessed by junior staff or less experienced intensivists.8 23 In a survey of ICU physicians in Italy, 86% of the respondents acknowledged having admitted patients inappropriately, with 33% attributing this to clinical doubt and 25% to assessment error.25 The long list of possible causes of indirect ICU admissions and delays makes it a challenge to prioritise interventions because each

cause calls for a different solution. To address the perennial problem of a full ICU, aside from the intuitive but operationally complex solution of increasing the number of beds, other recommendations include increasing the availability of intermediate or step-down care8 or alternative care areas for patients who require stabilisation;13 deployment of medical emergency teams or intensive care outreach services for ward patients becoming critically ill;13 18 26 27 and use of various models to expand physician coverage to provide critical care in the ED.28 Other factors and proposed interventions include the development of ward care pathways for conditions which frequently lead to ICU admissions15 and the development of predictive models and physiological early warning scores to identify incipient severe outcomes.16 18 Bringing in some elements of intensive care such as ventilators

to the general wards may not be enough to improve outcomes for critically ill patients. Tang found a significantly higher risk-standardised mortality among patients who were mechanically ventilated in the wards compared with the ICU.29 To enhance triage decisions, resources such as clinical guidelines are available for emergency physicians and intensivists to complement Drug_discovery their professional judgement. Examples include the American College of Critical Care Medicine’s Guidelines for ICU Admission, Discharge, and Triage,4 as well as Guidelines on Admission to and Discharge from the ICU and HDU of the UK Department of Health.30 The performance and accuracy of tools such as the Emergency Severity Index have been assessed.31 While, to a certain extent, existing tools minimise the subjectivity of patient assessments, there is a need to continuously improve the performance of these tools. With regard to limitations of this research, as this was a retrospective study, it was not possible to determine the reason for the initial refusal of indirect MICU/HDU admissions.