Commentary

Commentary: Critical care bed management: Can we do better?

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Can we do better?

What is the ideal number of ICU beds for any given hospital? Which criteria should be used to determine who gets those beds? Who is the best gatekeeper to equitably allow admission to the ICU? And is there an app for that? The “right” answers to these questions vary depending on who is providing you with the answer key.

Dr. Mike Waxman begins to unravel these complex issues and challenges us to do more with less. The data are clear that the ratio of ICU beds to general ward beds in U.S. hospitals is markedly increased, compared with other developed countries – and that we fill those beds with patients of lower acuity. Our epidemiology colleagues have made several other troubling observations of late: ICU admissions are growing fastest in patients aged 85 and older; most admissions from the ED are for symptoms – think chest pain or shortness of breath – that can signal a life-threatening condition but are more likely due to other problems; and the utilization of advanced imaging prior to ICU transfer has more than doubled in recent years. These findings suggest that factors such as changing demographics and medical-legal concerns are working against our “lean” approach to ICU care.

Equally troubling, many patients and non-ICU clinicians now view the hospital’s general ward vs. ICU bed designation on par with an airline gate agent’s coach vs. business class seat assignment. Through their eyes, patients receive more attention (2:1 nurse staffing and 24/7 in-house coverage anyone?) and more monitoring (Ah, I see you have the machine that goes “ping”) behind the velvet ropes of the ICU. Lost from their view, buried deep in the bowels of the electronic medical record, is the fact that three times as many dollars are spent on their care without any incremental benefit. Sadly, many cost-conscious intensivists who attempt to use evidence-based criteria for ICU triage are steamrolled into submission by such misinformed clinicians and/or administrators under the misplaced auspices of patient safety. Hopefully innovators such as Dr. Waxman will succeed in moving the needle and transform our JICU (just-in-case unit) beds back to ICU beds.

Dr. Lee E. Morrow, FCCP, is professor of medicine and professor of pharmacy at Creighton University, Omaha, Neb.


 

References

Is it possible to give the best critical care while spending less money and resources doing it? Can we reduce waste while improving quality in a so-called lean approach to critical care? I believe that we have too many critical care beds, and we fill some of those beds with patients who can be taken care of at less intense levels of care—which are also less expensive.

Most work that is done to improve critical care looks at the quality of care. This is an area where a lot of data are accumulating. Take septic shock, for example. In the recently published ProCESS trial (The ProCESS Investigators. N Engl J Med. 2014. 370[18]:1683), the 60-day in-hospital mortality for septic shock was 18.2% to 21.0%. A lot of institutions (including mine) are struggling to get their septic shock mortality rate under 30%. Although some people critique the ProCESS trial mortality rate on patient selection, most of us try to figure out how to duplicate that lower rate. We do this in areas other than septic shock. If we are comparable in whatever quality statistic, we applaud our success. If we aren’t comparable, we look at ways to improve, often based on what was done in that particular study.

Dr. Michael J. Waxman, FCCP

Dr. Michael J. Waxman, FCCP

How big of a financial burden is our critical care spending? According to an analysis of critical care beds by Halpern and colleagues (Crit Care Med. 2004;32[6]:1254), the number of hospital beds decreased 26.4% between 1985 and 2000, and the absolute number of critical care beds increased 26.2% (quantitated at 67,357 adult beds in 2007 per SCCM.org, www.sccm.org/Communications/Pages/CriticalCareStats.aspx). Critical care beds cost $2,674 per day in 2000, up from $1,185 (our CFOs tell us it is more like $3,500 to $4,000 per day now). They represented 13.3% of hospital costs, 4.2% of national health expenditures (NHE), and 0.56% of gross domestic product (GDP). There are 55,000 critically ill patients cared for each day in the United States, representing 5 million ICU patients per year. This is an enormous expenditure of money and it is growing.

Another interesting observation by Halpern and colleagues (Crit Care Med. 2004;32:1254) was that critical care beds were only at 65% occupancy. This reflects my own experience where we operate at a 70% average ICU bed occupancy. We have created a larger financial burden with the fixed costs of one-third more ICU beds than we actually use. Some bed availability is desirable, but how much is too much? Are we doing the best job to give quality care and spend money wisely? Can we be more efficient in the throughput of patients and in their care? Admission criteria should be part of any unit, designed to place all patients who need ICU care appropriately in the ICU and exclude those whose care can be managed at a lesser level of intensity and cost. Discharge criteria, care protocols (e.g., wake up and wean), checklists, and daily attention to the usual parameters (e.g., DVT prophylaxis) are essential for high-quality but efficient care. Done 24/7, we can maximize efficiency and quality with a minimum of ICU readmissions. Throughput is part of every physician’s job description. The physician who wants one more day for his or her patient in the ICU simply because the nurse has fewer patients misses a number of points. Why would anyone want more exposure to resistant organisms, more noise, more awakenings, and less sleep, just to name a few? Keeping that non-ICU patient in the ICU bed might even delay the transfer of another patient coming from the ED, where we know they often don’t get good ICU care.

Are the beds filled only with what we intensivists would consider legitimate ICU patients, defined by both generally accepted (endotracheal tube in place) and individually specified criteria (unit specific related to other unit capabilities)? That would impact cost. An interesting article by Gooch and Kahn (JAMA. 2014; 311[6]:567) discussed the demand elasticity of the ICU. They considered the changes in case mix of patients between days of high and low bed availability. They contended that when ICU beds were available, there was an increase in patients who were unlikely to benefit from ICU admission. This group included a population of patients likely to survive and whose illness severity was low and a population of patients who were unlikely to survive and had a high illness severity. In other words, admissions expand to fill the staff-able beds. If this is true, it is another area where better management could lower costs without reducing the quality of care.

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