In our September 2016 What's New in the Patient Safety World column “Too Much of a Good Thing” we noted some studies that suggested that some quality of care measures and even mortality might be lower at hospitals having high ICU utilization rates.
In that column we noted that the Society for Critical Care Medicine has just updated its guidelines for admission to and discharge from critical care units (Nates 2016). The guidelines also have recommendations for prioritization and triage of potential ICU patients based upon factors such as severity of illness, functional impairment, comorbidities, prognosis for recovery and quality of life, patient preferences with regard to life-sustaining treatment, etc. Chronological age should not be a primary determinant in the elderly. One important recommendation under discharge guidelines is to avoid “after hours” discharge (see our December 9, 2008 Patient Safety Tip of the Week “Huddles in Healthcare” regarding huddles with bed coordinators to avoid such after hours transfers from the ICU). The guidelines also discuss potential sites to which discharge from the ICU can occur, including general wards, step down units, post-acute care facilities, etc. They also discuss use of outreach programs to supplement ICU care, such as rapid response teams and ICU consult teams on wards.
Using those SCCM guidelines, Chang and colleagues (Chang 2016) retrospectively analyzed a year’s worth of ICU admissions at Harbor-UCLA Medical Center to determine appropriateness for ICU use. The levels were priority1 (critically ill and needing intensive treatment and monitoring that cannot be provided outside an ICU), priority 2 (not critically ill, but requiring close monitoring or potential immediate intervention), priority 3 (critically ill but with reduced likelihood of recovery because of underlying diseases or severity of acute illness), and priority 4 (not appropriate for ICU, similar outcomes can be achieved in non-ICU settings), and a fifth priority category they added for patients awaiting transfer out of the ICU.
Not surprisingly, only 46.9% were determined to be priority 1 so just over 50% were deemed to potentially have received adequate care in non-ICU settings. And 65% of total ICU bed days were “allocated to care that was considered discretionary monitoring (priority 2), low likelihood of benefit despite critical illness (priority 3), or manageable in non-ICU settings (priority 4 or 5).”
Of the priority 3 patients (those critically ill but having an underlying disease that led to a limited likelihood of recovery), 26% had advance malignant neoplasms and 27% had advanced dementia.
We’re not surprised by the findings. For years we (medical director and director of nursing) would periodically do “ICU Bed Rounds” where we similarly assessed appropriateness for ICU level care, albeit with criteria that were less well-established than those in the SCCM guidelines. We also routinely found that about half the patients could be receiving care in alternative sites.
We recognized several factors that contributed to putting patients in an ICU who could have received adequate care elsewhere. Sometimes it was pressure from families to “do everything possible”. Other times it was pressure from housestaff to move “sicker” patients to a different service. Occasionally, it was unavailability of “downstream” beds. But there were other less obvious factors. Most prominent was the disconnect between a physician’s concern that a patient needs a higher level of nursing care when what the patient needed primarily was monitoring. For example, patients who were stable but had conditions that could conceivably have fatal outcomes were often put in the ICU for monitoring even though they actually needed very little nursing intervention (roughly equivalent to priority 2 in the SCCM guidelines). Second, Roemer’s Law (if you have beds someone will fill them) applies. While Roemer’s Law was intended to apply to a region’s supply of hospital beds, the same concept applies to ICU beds within a hospital. A third, and usually unmentionable, factor has to do with reimbursement. While hospital reimbursement may or may not be impacted by the level of care utilized by patients, there may be physician reimbursement issues (for daily care and for procedures) that serve as barriers to moving patients to other levels of care. You’d be surprised how ICU utilization can be reduced if your intensivists are paid in a manner that removes such financial incentives “to do more”. As long as hospitals are on a DRG (or other fixed payment) methodology and physicians on a fee-for-service methodology you will always have conflicts of interest that impact both total hospital utilization and ICU utilization.
Chang and colleagues also point out that there are other important factors, such as the level of availability of monitoring and care in the non-ICU areas. You’ll recall that we have even recommended ICU care for some high-risk patients (such as a patient with sleep apnea receiving opioids) if continuous physiological monitoring and capnography are not available on a med-surg floor or step-down unit.
Our previous column concluded that hospitals need to take a close look at their ICU utilization. We still see hospitals that lack formal criteria for ICU admission and discharge or have them but don’t adhere to them. Yes, ICU’s provide patients with levels of nursing care and monitoring that should be advantageous but they also expose patients to a variety of potential hazards (nosocomial infections, invasive procedures, etc.). And provision of services that don’t result in better patient outcomes may be detrimental to the fiscal health of the hospital.
Nates JL, Nunnally M, Kleinpell R, et al. ICU Admission, Discharge, and Triage Guidelines. A Framework to Enhance Clinical Operations, Development of Institutional Policies, and Further Research. Crit Care Med 2016; 44(8): 1553-1602
Chang DW, Dacosta D, Shapiro MF. Priority Levels in Medical Intensive Care at an Academic Public Hospital. JAMA Intern Med 2016; Published online December 27, 2016