Critical care delivery and outcomes in critically ill emergency patients with a documented limitation of ICU admission: a retrospective cohort study

Abstract

Data on management and outcomes of critically ill emergency patients with a limitation of intensive care unit (ICU) admission are. We investigated critical care delivery, process measures and patient outcomes in patients with a documented limitation of ICU admission treated in a Critical Care Resuscitation Unit (CCRU). Retrospective, single-centre study including adult, non-traumatic emergency patients admitted to the CCRU of a tertiary academic hospital between October 2022 and April 2025. Patients were included if a decision not to proceed with ICU admission had been documented before or during CCRU care. Data were extracted from electronic medical records. The primary study objective was to determine survival and discharge outcomes, symptom-control interventions, and goals-of-care discussions and documentation. Associations with in-hospital and 28-day mortality were evaluated using Firth penalized logistic regression. Among 1,294 CCRU admissions during the study period, 139 patients (10.7%) had a documented limitation of ICU admission. Ten patients (7.2%) were considered to have entered the irreversible dying process at CCRU admission, while 129 patients (92.8%) received a time-limited episode of critical care. Discussions with patients and families about goals of care were held in 24 [17.3% (95% CI, 11.4–24.6%)] and 88 [63.3% (95% CI, 54.7–71.3%)] patients, respectively. Goals of care were defined and documented in 135 of 139 [97.1% (95% CI, 94.3–99.9%)] subjects. Seventy-four patients [53.2% (95% CI, 45.0–61.3%)] survived to hospital discharge. At 28 days, 58 of 124 patients with available survival status were alive [46.8% (95% CI, 38.0-55.6%)]. Of 46 hospital survivors who had lived at home before CCRU admission, 36 (78.3%) returned home. Higher SOFA scores at CCRU admission were associated with in-hospital mortality [adjusted OR, 1.50 (95% CI, 1.26–1.85); p  < 0.001] and 28-day mortality [adjusted OR, 1.44 (95% CI, 1.20–1.78); p  < 0.001]. Among critically ill emergency patients with a documented limitation of ICU admission, CCRU care combined time-limited episodes of critical care with goals-of-care determination and symptom-directed or palliative care. More than half of patients survived to hospital discharge, and most survivors who had previously lived at home returned home.