Copyright © Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited. Admission and discharge of critically ill patients Maurizia Capuzzo a , Rui P. Moreno b and Raffaele Alvisi a Introduction The intensive care unit (ICU) is a hospital unit providing continuous surveillance and highly specialized care to acutely ill patients, either medical or surgical, whose conditions are life-threatening and require comprehen- sive care. The intensivists taking care of these patients are not specialists of organ or apparatus, but they are specialists of acuity, that is severity of the illness and risk of the patient [1]. The organization models of the ICU are commonly described as ‘open’ or ‘closed’ [2]. In the former model, which is widespread in the USA, the primary physician chooses whether to admit the patient, prescribes treat- ments, maintains the responsibility for any patient man- agement decisions, and requires the consultation of other specialists, including the intensivist, if necessary. In the latter model (‘closed’) the intensivist takes on the senior role whereas the patient’s primary physician acts as a consultant for the period the patient passes in the ICU. This ‘closed’ model is used in most of the European countries as well as in Australia and New Zealand [3]. However, also if the ICU admission and discharge de- cisions are taken by different physicians in the ‘open’ or ‘closed’ units, common criteria should exist in order to guarantee equity in the interest of the patient and the society. Rules for admission to ICU The first article giving rules for adult patient admission to ICU was published in 1988 [4] and revised in 1999 [5], and another creating a framework for developing multi- disciplinary admission and discharge policies for pediatric ICUs was published in the same year [6]. Really, some National Societies have reported any guidelines in their website (www.sfar.org) or journal [7], but the topic does not seem to be a major point of discussion. All these guidelines for adults [4,5,7] stress that the categories of patients who do not take benefit from the ICU are those ‘too well to benefit’ and those ‘too sick to benefit’. Unfortunately, physician appraisal of underlying disease severity is potentially vulnerable to a number of poten- tially relevant biases [8]. Moreover, the decision to admit a patient to the ICU may be influenced not only by a Department of Surgical, Anaesthetic and Radiological Sciences, University Hospital of Ferrara, Ferrara, Italy and b Unidade de Cuidados Intensivos Polivalente, Hospital de St. Anto ´ nio dos Capuchos, Centro Hospitalar de Lisboa Central E.P.E., Lisbon, Portugal Correspondence to Maurizia Capuzzo, MD, Dipartimento di Scienze Chirurgiche, Anestesiologiche e Radiologiche, Sezione di Anestesia e Rianimazione, Azienda Ospedaliero-Universitaria S. Anna di Ferrara, Corso Giovecca 203, 44100 Ferrara, Italy Fax: +39 0532 247160; e-mail: cpm@unife.it Current Opinion in Critical Care 2010, 16:499–504 Purpose of review The intensive care unit (ICU) provides continuous surveillance and specialized care to acutely ill patients. The decisions on patient admission and discharge should be based on common clinical criteria in order to guarantee equity. Recent findings The survival benefit of early admission to intensive care has been demonstrated recently. Sometimes, the number of potential patients may exceed the available beds making triage of the patients necessary. The prioritization model based on the benefit that the patient can have from the admission is the most used. In the case of the outbreak peak of pandemic A H1N1 flu, a triage plan using Sequential Organ Failure Assessment score combined with inclusion and exclusion criteria to complement clinical judgment has been recommended. Nevertheless, studies have shown that this triage could lead to withdrawal of life support in patients who survive. Triage implies refusal of some patients, and refusal rates vary greatly even across the same country. Policies for discharge from intensive care show wide variability influenced by the availability of step-down facilities. Summary The decisions to admit and discharge patients depend on patient, structure and physician-related variables. Early ICU admission of the critically ill patient is beneficial. Future analysis should also investigate economic parameters. Keywords critical care, intensive care, organization, patient admission, patient discharge Curr Opin Crit Care 16:499–504 ß 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins 1070-5295 1070-5295 ß 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins DOI:10.1097/MCC.0b013e32833cb874