Objective: To describe intensive care unit referral decisions by emergency room physicians in patients aged > or =80 yrs.
Design: Prospective, observational cohort study of patients aged > or =80 yrs who were triaged in the emergency room, using a list of intensive care unit admission criteria selected by emergency physicians among 76 preliminary criteria adapted from the 1999 Society of Critical Care Medicine guidelines. The Delphi method was used to select the criteria.
Setting: Fifteen French hospitals.
Patients: A total of 2646 patients aged > or =80 yrs with at least one criterion.
Interventions: None.
Measurements and main results: In the Delphi process, level of agreement was assessed as follows: when all answers fell within a single interval (7-9 = definite admission criteria; 4-6 = equivocal admission criteria or 1-3 = inappropriate admission), agreement was strong; when answers spanned two intervals, agreement was fair; and when answers spanned all three intervals, agreement was poor. Of the 76 preliminary criteria, two were removed; 44 were selected as definite intensive care unit admission criteria; and 30 were selected as equivocal intensive care unit admission criteria. Of the 1426 patients meeting definite admission criteria, 441 (30.9%) were referred for intensive care unit admission and 231 of 441 (52.4%) were admitted to the intensive care unit. Of the 1041 patients with equivocal admission criteria, 181 (17.3%) were referred for intensive care unit admission; and, of these, 79 (43.6%) were admitted to the intensive care unit. Factors associated independently with no intensive care unit referral were age odds ratio [OR], 1.04; 95% confidence interval [CI], 1.04-1.07), active cancer (OR, 1.61; 95% CI, 1.09-1.38), unknown hospitalization status (OR, 1.53; 95% CI, 1.11-2.11), unknown living arrangements (OR, 1.69; 95% CI, 1.19-2.42), regular psychotropic medications (OR, 1.42; 95% CI, 1.10-1.81), low severity at referral (OR, 0.60; 95% CI, 0.53-0.68), low activity in daily living score (OR, 0.93; 95% CI, 0.88-0.99).
Conclusions: Emergency and intensive care unit physicians were extremely reluctant to consider intensive care unit admission of patients aged > or =80 yrs, despite the presence of criteria indicating that intensive care unit admission was certainly or possibly appropriate.