In recent decades, healthcare has become more and more expensive, triggering calls for cost-effective care in an increasingly cost-conscious despite and quality-conscious environment. Intensive care unit (ICU) beds are scarce hospital resources reserved for a select subset of hospital patients. Underlying the scarcity of ICU beds is the high start-up and operating cost of the unit as well as the highly specialised training required of the staff. While the total cost of ICU admission varies widely, the daily cost of ICU care per patient is approximately three to four times more

than that in the general ward.1–4 Despite ICU beds comprising only between 1.2–6.3% of all hospital beds, ICU services are estimated to take up 15–20% of the total hospital budget.5 Given the scarcity of ICU beds, priority is given to patients with serious but potentially reversible conditions who may benefit from more intensive observation and treatment than is provided in the general ward.4 6 To a certain extent, guidelines can reduce the arbitrariness of triaging patients to the ICU. However, the ultimate decision to admit a patient

to the ICU depends largely on the individual physician’s preference, professional judgement and experience. A benchmarking study found a wide variation across ICUs in the proportion of critical care patients admitted for active critical care treatment versus monitoring alone.7 Depending on the institution, between 20% and 98% of patients admitted to the ICU required active treatment.7 The benefits gained from the ICU as a scarce resource can be maximised not just through the right siting of care, but also by ensuring that critically ill patients are admitted without delay. Numerous factors have been cited for delays in admitting

critically ill patients from the emergency department (ED) to the ICU. Commonly implicated factors include the lack of available ICU beds,8–12 the underlying disease itself,8 13 organisational issues9 and frontline health professionals’ inability to recognise the seriousness of the condition.14 15 Regardless of the cause, delayed ICU admissions may ultimately have the same detrimental effect on the patient. GSK-3 This study aimed to determine if severely ill patients indirectly admitted from the ED to the general wards and subsequently to the medical ICU (MICU) or high dependency unit (HDU) have a greater risk of adverse outcomes than those who were admitted directly from the ED to the MICU or HDU. The main outcomes of interest included in-hospital and 60-day mortality, ICU as well as total hospital length of stay. Methods Plan of investigation This was a retrospective cohort study conducted in a tertiary level acute care public hospital in Singapore. In this hospital, after assessing the patient’s need for ICU care, the ED physician refers the patient to the intensivist on-call.