Intensive Care Unit Bed Availability Research Articles

Comparison of Medical Admissions to Intensive Care Units in the United States and United Kingdom

The United States has seven times as many intensive care unit (ICU) beds per capita as the United Kingdom; the effect on care of critically ill patients is unknown. To compare medical ICU admissions in the United States and United Kingdom. Retrospective (2002-2004) cohort study of 172,785 ICU admissions (137 United States ICUs, Project IMPACT database; 160 United Kingdom ICUs, Case Mix Program) with patients followed until initial hospital discharge. United Kingdom (vs. United States) admissions were less likely to be admitted directly from the emergency room (ER) (33.4% vs. 58%); had longer hospital stays before ICU admission (mean days 2.6 ± 8.2 vs. 1 ± 3.6); and fewer were greater than or equal to 85 years (3.2% vs. 7.8%). United Kingdom patients were more frequently mechanically ventilated within 24 hours after ICU admission (68% vs. 27.4%); were sicker (mean Acute Physiology Score 16.7 ± 7.6 vs. 10.6 ± 6.8); and had higher primary hospital mortality (38% vs. 15.9%; adjusted odds ratio, 1.73; 95% confidence interval, 1.50-1.99). There was no mortality difference for mechanically ventilated patients admitted from the ER (adjusted odds ratio, 1.09; 95% confidence interval, 0.89-1.33). Comparisons of hospital mortality were confounded by differences in case mix; hospital length of stay (United Kingdom median 10 d [interquartile range {IQR}, 3-24] vs. United States 6 d [IQR, 3-11]; and discharge practices (more United States patients were discharged to skilled care facilities [29% of survivors vs. 6% in the United Kingdom]). Lower United Kingdom ICU bed availability is associated with fewer direct admissions from the ER, longer hospital stays before ICU admission, and higher severity of illness. Interpretation of between-country hospital outcomes is confounded by differences in case mix, processes of care, and discharge practices.

Care of the Intubated Emergency Department Patient

Emergency physicians perform tracheal intubation and initiate mechanical ventilation for critically ill patients on a daily basis. With the current national challenges of intensive care unit bed availability, intubated patients now often remain in the emergency department (ED) for exceedingly long periods of time. As a result, care of the intubated patient falls to the emergency physician (EP). Given the potential for significant morbidity and mortality, it is crucial for the EP to possess the most current, up-to-date information pertaining to the care of intubated patients. This article discusses critical aspects in the ED management of intubated and mechanically ventilated patients. Specifically, emphasis is placed on providing adequate sedation and analgesia, limiting the use of neuromuscular blocking agents, correctly setting and adjusting the mechanical ventilator, utilizing appropriate monitoring modalities, and providing key supportive measures. Despite these measures, inevitably, some patients deteriorate while receiving mechanical ventilation. The article concludes with a discussion outlining a step-wise approach to evaluating the intubated patient who develops respiratory distress or circulatory compromise. With this information, the EP can more effectively care for ventilated patients while minimizing morbidity, and ultimately, improving outcome. Essential components of the care of intubated ED patients includes administering adequate sedative and analgesic medications, using lung-protective ventilator settings with attention to minimizing ventilator-induced lung injury, elevating the head of the bed in the absence of contraindications, early placement of an orogastric tube, and providing prophylaxis for stress-related mucosal injury and deep venous thrombosis when indicated.

Establishing a Cardiac Surgery Recovery Unit within the Post Anaesthesia Care Unit

At the Austin & Repatriation Medical Centre (A&RMC) an innovative approach was taken to improve the reliability of ICU bed availability for elective cardiac surgery patients. A cardiac surgery recovery unit (CSRU), a dedicated three bed area, was established within the Post Anaesthesia Care Unit (PACU) so as to deliver care to a group of patients that had previously been provided in the Intensive Care Unit (ICU). Derived benefits arising from this initiative include a reduction in the number of cardiac surgery cancellations for want of ICU beds, reduced length of stay of patients in the CSRU and in the Medical Centre, and an improvement in the level of knowledge and skills of PACU nurses in relation to caring for the specific needs of acutely ill patients.

Reducing resource consumption through work redesign in a surgical intensive care unit: A multidisciplinary, protocol-based progressive care area

Patients with prolonged intensive care unit (ICU) length of stay, though few in number, consume as much as 50% of ICU resources. With increasing pressures for cost containment in health care, the availability of ICU beds may be jeopardized. To improve the efficiency of care for patients requiring a surgical intensive care unit (SICU) stay of 3 or more days, a multidisciplinary, highly “protocolized,” Progressive Care Area was developed within the existing SICU environment. Entry into this area is limited to patients whose acuity level is not high by ICU standards, but too high for a general surgical floor. In designing the Progressive Care Area, we drew on a number of published management strategies—including total quality management concepts and our prior experience in establishing ventilator management teams. The Progressive Care Area has resulted in a reduction in both the frequency and variation of resources used. A Progressive Care Area within an existing ICU is a viable alternative for the care of the patients who have prolonged lengths of stay and are less acutely ill, and it significantly improves ICU efficiency. (Heart Lung® 1997; 26: 329-34)

Ethics in intensive medicine

In more than 30 years of development of intensive care medicine (ICM), our specialty has acquired moral and ethical standpoints, although not without public pressure and discussions. Special commissions dealing, e.g., with brain death, terminal care, ethics of foregoing life-sustaining treatment in the critically ill, withholding or withdrawing mechanical ventilation, and other issues have been formed in a number of medical societies. International consensus conferences have helped to clarify some of the issues. With increasing experience, a multitude of ethical problems have arisen in ICM that have to be dealt with, such as the issue of quality of life. What is an unworthy life? Are we allowed to make judgments for our patients? What is cost-effectiveness in ICM? Other restrictions include bed and equipment shortages in the intensive care unit (ICU), the necessity for triage--undisputed in catastrophe medicine--and how one should proceed in managing elective patients? In situations of limited ICU bed availability, sicker patients will be admitted, sparing out patients who are less ill for observation and those with poor quality of life and poor prognosis. For the future, it will likely be necessary to define the patients who should be admitted to an ICU more than those who should not be admitted. An ICU treatment entitlement index would be directly proportional to the probability of successful outcome and the quality of the remaining life, and would be inversely related to costs for achieving success. The ICU outcome with survival, hospital mortality, and follow-up of ICU patients is considered. DNR (do not resuscitate), the dying patient, terminal care, terminal weaning--DNT (do not treat)--active and passive euthanasia, living wills, quality of life, and cost-effectiveness for ICU patients are defined. Their application in the ICU will be discussed and problems pointed out. Outcome predictions using scores (APACHE III, SAPS II, MPM) have been developed based on previous experience, but should only be applied to patient groups and for quality assurance in ICUs. The most frequent and difficult problem in the ICUs is the vegetative state, which requires an exact diagnosis. The differential diagnosis from other comatose states such as coma, brain death, and locked-in-syndrome is depicted. The ethics of interrupting life-sustaining treatment in critically ill patients have been worked out by a Task Force on Ethics of the Society of Critical Care Medicine (1990). A consensus was found that the patient may judge to forego therapy; ethically it is then appropriate to withhold or withdraw therapy. According to the consensus, withdrawing an already initiated treatment should not necessarily be regarded as more problematic than a decision not to initiate treatment. In my mind, however, there is a great difference between withdrawing or withholding, e.g., ventilation. A dissentive opinion by some members of the Task Force stated that hydration and nutrition other than high-technology or parenteral nutrition are key components of patient care, and should not be equated with medical intervention. The ethical problems associated with active euthanasia (physician-assisted suicide or death) as practised in the Netherlands are also discussed. In most countries this practice seems unacceptable. From 30 years experience in ICM, there are many more ethical questions and case reports without clear solutions. Care decisions for single patients in unacceptable situations should be made after medical evaluation by the intensivist with the medical team and, if possible, by the patient and/or his or her surrogate. Legislation and solutions cannot be expected for single patients, but ethics committees could be helpful in decision-making.

The intensive care units in greater Athens: needs and resources.

The purpose of this study was to investigate the availability of intensive care unit (ICU) beds and the number of requests, the number and categories of nursing staff, the nursing care required, and the time spent in various nursing activities. 19 district general hospitals were studied. The characteristics of the units and their nursing personnel were recorded. The availability of ICU beds, the frequency of bed requests, and the way of patient admission in the ICUs were studied retrospectively for 1 year and prospectively for 2 weeks. The staffing level of direct care for 36 patients was studied to determine the time required for direct nursing care. the distribution of intensive care beds was: GICU 108, CICU 114, PSICU 30. During 1991, 12363 patients were admitted and 12172 of them were discharged; 3 628 patients stayed less than 2 days while the average length of stay was 12.5 days. In 1992, during the 2-week period, there were 303 requests for an admission to ICUs and of these 150 requests could not be met because of lack of ICU beds. The mean staffing level was 2.3 nurses per bed (to cover the three shifts). The mean nursing time required for direct nursing care of each patient per shift was found to be 6 hours for GICU patients, 5.3 for CICU, and 6.0 for PSICU patients.

Rationing, Justice, and the American Physician

There are two articles in this week's issue ofThe Journalthat address the important question of what happens when demand for sophisticated medical services, in this case intensive care treatment, exceeds supply. If you haven't already done so, read the article by Strauss et al¹first. These investigators were able to cleverly relate the number of available intensive care unit (ICU) beds to physicians' admitting and discharge decisions by matching the number of open beds to the characteristics of patients admitted. What happened when there were few or no empty beds? Medical and surgical patients who were not very ill—for example, patients with chest pain but with a low probability of having a myocardial infarction—the "too healthy," were excluded. This study is the first to directly link daily variations in ICU bed availability to physicians' decision making. Its theme, however, is one that I increasingly hear during conferences