We all assume that ICU’s are good things and that you’ll receive better and safer care in an ICU almost regardless of what your medical problem is. But a new study challenges that assumption. Researchers from the University of Michigan (Valley 2016) analyzed data from Medicare’s Hospital Compare database and found that hospitals with high ICU use for patients with acute MI or CHF exacerbation often had higher mortality rates and lower rates of using evidence-based testing and treatments. For example, MI patients in high ICU use hospitals were less likely to receive aspirin on arrival. MI patients treated in high-ICU hospitals were 6 percent more likely to die within 30 days than patients admitted to low-ICU hospitals, and the difference was about 8 percent for heart failure patients. Hospitals treating smaller numbers of MI and CHF patients and for-profit hospitals tended to have higher use of ICU beds. Patients from lower income zip codes also tend to be overrepresented in the high-ICU hospitals.
Some of the same researchers last year identified similar findings in patients with pneumonia (Sjoding 2015). Hospitals with the highest rates of ICU admission for Medicare patients with pneumonia were less likely to deliver pneumonia processes of care (such as appropriate initial antibiotics and pneumococcal vaccination) and had worse outcomes (higher 30-day mortality and higher readmission rates) for Medicare patients with pneumonia. Hospital spending for pneumonia patients was also higher in high-ICU hospitals.
Somewhat difficult to reconcile with the latter study was another one by many of the same researchers (Valley 2015). They found in Medicare patients with pneumonia that patients with “discretionary” admission to ICU’s had a significantly lower adjusted 30-day mortality. That means that patients who were “borderline” for ICU admission actually had a mortality benefit over those with similar features who were admitted to general wards. That was the opposite of what the researchers expected to find. It is not really clear why these findings differed from those in the Sjoding 2015 study.
Another new study looked at the associations between hospital-level ICU utilization rates and risk-adjusted hospital mortality, use of invasive procedures, and hospital costs (Chang 2016). For each of the 4 medical conditions studied (DKA, PE, UGIB, and CHF) hospital-level ICU utilization rate was not associated with hospital mortality. But use of invasive procedures and costs of hospitalization were greater in institutions with higher ICU utilization for all 4 conditions. They also found that hospitals had similar ICU utilization patterns across the 4 medical conditions studied, suggesting that systematic institutional factors may influence decisions to potentially overutilize ICU care.
Fortunately, in a timely release, 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.
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.
Update: see our January 2017 What's New in the Patient Safety World column “”
Valley TS, Sjoding MW, Goldberger ZD, Cooke CR. Intensive care use and quality of care for patients with myocardial infarction and heart failure. Chest 2016; In Press Accepted Manuscript, Available online 15 June 2016
Sjoding MW, Prescott HC, Wunsch H, Iwashyna TJ, Cooke CR. Hospitals with the highest intensive care utilization provide lower quality pneumonia care to the elderly. Crit Care Med 2015; 43(6): 1178-1186
Valley TS, Sjoding MW, Ryan AM, Iwashyna TJ, Cooke CR. Association of Intensive Care Unit Admission With Mortality Among Older Patients With Pneumonia. JAMA 2015; 314(12): 1272-1279
Chang DW, Shapiro MF. Association Between Intensive Care Unit Utilization During Hospitalization and Costs, Use of Invasive Procedures, and Mortality. JAMA Intern Med 2016; Published online August 08, 2016
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