Characteristics and Outcomes of Patients Referred but Declined for ICU Admission in South Africa

Monday, March 23, 2026

2:30 PM - 3:30 PM Central Time

Location: Connections Central - RST 01

George L. Anesi, MD, MSCE, FCCM

University of Pennsylvania, Pennsylvania

Disclosure(s): University of Pennsylvania: University Grants/Research Support (Ongoing); Various law firms and clients (expert witness): Consulting fees or other remuneration (Ongoing), Speaker/Honoraria (includes speakers bureau, symposia, and expert witness) (Ongoing); Wolters-Kluwer UpToDate: Receipt of Royalties (Ongoing)
NN

Nqobile Ndadane, MBChB

Department of Anaesthesia and Critical Care
Greys Hospital, KwaZulu-Natal Department of Health, KwaZulu-Natal, South Africa

Disclosure information not submitted.
JI

Jonathan Invernizzi, MBBCh, MMed

Department of Anaesthesia and Critical Care
Harry Gwala Regional Hospital, KwaZulu-Natal Department of Health, KwaZulu-Natal, South Africa

Disclosure information not submitted.
SA

Saajid Ally Alladeen, MBChB, DA

Department of Anaesthesia and Critical Care
Harry Gwala Regional Hospital, KwaZulu-Natal Department of Health, KwaZulu-Natal, South Africa

Disclosure information not submitted.
AR

Arisha Ramkillawan, MBChB

Department of Anaesthesia and Critical Care
Greys Hospital, KwaZulu-Natal Department of Health, KwaZulu-Natal, South Africa

Disclosure information not submitted.
SS

Stella M. Savarimuthu, MD

Assistant Professor of Medicine
University of Rochester Medical Center, New York

Disclosure information not submitted.
RW

Robert D. Wise, MBChB, MMed

Intensive Care Department
John Radcliffe Hospital, Oxford University Trust Hospitals, England, United Kingdom

Disclosure information not submitted.
MS

Michelle T.D. Smith, MBChB, PhD

Department of Anaesthesia and Critical Care
School of Clinical Medicine, University of KwaZulu-Natal, KwaZulu-Natal, South Africa

Disclosure information not submitted.
ZF

Zane Farina, MBChB

Department of Anaesthesia and Critical Care
Greys Hospital, KwaZulu-Natal Department of Health, KwaZulu-Natal, South Africa

Disclosure information not submitted.

Introduction: ICU beds are a limited resource, especially in low- and middle-income countries. Critical care teams may use prioritization strategies to admit patients most likely to benefit. Understanding how well this prioritization works, and what happens to patients declined for ICU admission, will inform further care delivery optimization.

Methods: The SA-ICU-Strain Study Group performed a descriptive, exploratory, retrospective cohort study in two public hospitals in the KwaZulu-Natal Department of Health, South Africa, January – June 2022. Adult patients referred for ICU admission were classified as ICU admissions or, by SCCM Triage Priority scores, as low or high acuity declined ICU referrals. Patient characteristics and 30-day all-cause in-hospital mortality were extracted from the ICU registry and hospital mortuary records.

Results: Among 866 ICU referrals, 469 (58.9%) were admitted and 397 (45.8%) were declined for ICU admission. ICU admissions had an observed mortality of 27.7%. Among declined ICU referrals with non-missing triage priority scores, 188 (23.6%) high acuity declined ICU referrals had a 42.0% mortality, and 139 (17.5%) low acuity declined ICU referrals had a 7.2% mortality. Among declined ICU referrals, there were 109 high acuity survivors and 10 low acuity decedents: clinical deviations from triage-expected trajectories. Compared to high acuity decedents, non-admitted high acuity survivors were younger (44.6 vs 49.1 years), more likely surgical referrals (68.5 vs 52.3%), less likely to be mechanically ventilated (24.8 vs 41.8%), more likely to have a qSOFA score < 2 (70.4 vs 41.2%), and less likely to have chronic cardiovascular disease (14.7 vs 24.1%) or sepsis (16.5 vs 25.3%). Compared to low acuity survivors, non-admitted low acuity decedents were older (48.3 vs 39.1 years), more likely male (60.0 vs 50.4%), more likely referred from the operating theatre (50.0 vs 23.3%) and less likely from the emergency department (10.0 vs 27.9%), and more likely to have an acute respiratory process (50.0 vs 19.4%) or acute metabolic derangements (60.0 vs 35.7%).

Conclusions: SCCM Triage Priority scores achieve separation of high and low acuity ICU referrals, but among patients declined for ICU admission, there remain patients with clinical deviations from triage-expected trajectories.