Addressing the Growth in Intensive Care

Seymour, Christopher W.; Kahn, Jeremy M.

doi:10.1001/archinternmed.2012.3773

Cited by 6 publications

(5 citation statements)

References 9 publications

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“…Nearly 65% of total ICU days were allocated to care that was considered discretionary monitoring (priority 2), low likelihood of benefit despite critically illness (priority 3), or manageable in non-ICU settings (priority 4 and 5). Our findings suggest that ICU care is inefficient, devoting substantial resources to patients less likely to benefit . Determining appropriateness of ICU care is complex; in addition to expected benefit, it must incorporate patient preferences, availability of ICU resources, and levels of medical complexity manageable in non-ICU settings.…”

Section: Discussionmentioning

confidence: 94%

Priority Levels in Medical Intensive Care at an Academic Public Hospital

2017

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It seems that we increasingly walk by homeless people sleeping-or trying to sleep-on a cold sidewalk near the warmth of a heating vent. Even for those who secure a place in a shelter, it can be difficult to sleep in an unfamiliar, often crowded, and sometimes insecure place. Perhaps it's obvious that homeless people are more likely to have difficulty sleeping than people who sleep in their own homes. But given the importance of sleep for good physical and mental health, we think the work of Léger et al 1 in this issue of JAMA Internal Medicine in quantifying the prevalence of sleep problems in the homeless is important, and lays groundwork to start to address this problem. We recognize that the homeless population and homeless services are different in France than in the United States, but we believe that the magnitude of the problem of poor sleep is likely similar in homeless persons everywhere.

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Section: Discussionmentioning

confidence: 94%

Priority Levels in Medical Intensive Care at an Academic Public Hospital

2017

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“…Thus, we may accommodate part of the surging demand for critical care by increasing ICU efficiency rather than using the higher-cost approach of building more ICU beds (33–38). …”

Section: Discussionmentioning

confidence: 99%

Outcomes Among Patients Discharged From Busy Intensive Care Units

Wagner¹,

Gabler²,

Ratcliffe³

et al. 2013

Ann Intern Med

125

116

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Background Strains on the capacities of intensive care units (ICUs) may influence the quality of ICU-to-floor transitions. Objective To determine how 3 metrics of ICU capacity strain (ICU census, new admissions, and average acuity) measured on days of patient discharges influence ICU length of stay (LOS) and post–ICU discharge outcomes. Design Retrospective cohort study from 2001 to 2008. Setting 155 ICUs in the United States. Patients 200 730 adults discharged from ICUs to hospital floors. Measurements Associations between ICU capacity strain metrics and discharged patient ICU LOS, 72-hour ICU readmissions, subsequent in-hospital death, post–ICU discharge LOS, and hospital discharge destination. Results Increases in the 3 strain variables on the days of ICU discharge were associated with shorter preceding ICU LOS (all P < 0.001) and increased odds of ICU readmissions (all P< 0.050). Going from the 5th to 95th percentiles of strain was associated with a 6.3-hour reduction in ICU LOS (95% CI, 5.3 to 7.3 hours) and a 1.0% increase in the odds of ICU readmission (CI, 0.6% to 1.5%). No strain variable was associated with increased odds of subsequent death, reduced odds of being discharged home from the hospital, or longer total hospital LOS. Limitation Long-term outcomes could not be measured. Conclusion When ICUs are strained, triage decisions seem to be affected such that patients are discharged from the ICU more quickly and, perhaps consequentially, have slightly greater odds of being readmitted to the ICU. However, short-term patient outcomes are unaffected. These results suggest that bed availability pressures may encourage physicians to discharge patients from the ICU more efficiently and that ICU readmissions are unlikely to be causally related to patient outcomes. Primary Funding Source Agency for Healthcare Research and Quality; National Heart, Lung, and Blood Institute; and Society of Critical Care Medicine.

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“…Such data further supports calls to limit the addition of ICU beds to an already inefficient system. (31, 32)…”

Section: Discussionmentioning

confidence: 99%

County-Level Effects of Prehospital Regionalization of Critically Ill Patients

Seymour

Alotaik

Wallace

et al. 2015

Critical Care Medicine

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Objective Regionalization may improve critical care delivery, yet stakeholders cite concerns about its feasibility. We sought to determine the operational effects of prehospital regionalization of non-trauma, non-arrest critical illness. Design Discrete event simulation study Patients and setting All 2006 hospital discharge data from King County, Washington, linked to all adult, eligible patients transported by county EMS agencies. Methods We simulated active triage of high-risk patients to designated referral centers using a validated prehospital risk score; we studied three regionalization scenarios: (1) up triage, (2) up & down triage, (3) up & down triage after reducing intensive care unit (ICU) beds by 25%. We determined the effect on patient routing, ICU occupancy at referral and non-referral hospitals, and EMS transport times. Measurements and Main Results 119,117 patients were hospitalized at 11 non-referral centers and 76,817 patients were hospitalized at three referral centers. Among 20,835 EMS patients, 7,817 (43%) patients were eligible for up triage and 10,242 (57%) patients were eligible for down triage. At baseline mean daily ICU bed occupancy was 61% referral and 47% at non-referral hospitals. Up-triage increased referral ICU occupancy to 68%, up and down triage to 64%, and up and down triage with bed reduction to 74%. Mean daily non-referral ICU occupancy did not exceed 60%. Total EMS transport time increased by less than 3% with up and down triage. Conclusions Regionalization based on prehospital triage of the critically ill can allocate high-risk patients to referral hospitals without adversely affecting ICU occupancy or prehospital travel time.

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Addressing the Growth in Intensive Care

Cited by 6 publications

References 9 publications

Priority Levels in Medical Intensive Care at an Academic Public Hospital

Priority Levels in Medical Intensive Care at an Academic Public Hospital

Outcomes Among Patients Discharged From Busy Intensive Care Units

County-Level Effects of Prehospital Regionalization of Critically Ill Patients

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