Abstract:OBJECTIVE To estimate the required number of public beds for adults in intensive care units in the state of Rio de Janeiro to meet the existing demand and compare results with recommendations by the Brazilian Ministry of Health.METHODS The study uses a hybrid model combining time series and queuing theory to predict the demand and estimate the number of required beds. Four patient flow scenarios were considered according to bed requests, percentage of abandonments and average length of stay in intensive care u… Show more
“…Absence of acute respiratory failure and evaluation over the phone were determinants of refusal. Among recent studies, a strong effect of bed availability [ 10 ] and older age [ 16 - 18 ]. On ICU refusal was found.…”
Introductionintensive care unit (ICU) beds are a scarce resource, and admissions may require prioritization when demand exceeds supply. However, there are few data regarding both outcomes of admitted patients to intensive care unit (ICU) in comparison with outcomes of not admitted patients. The aim of this study was to assess reasons and factors associated to refusal of admission to ICU as well as the impact on mortality at 28 days and patients' outcomes.MethodsSingle-center, cross-sectional descriptive study conducted in 8-bed Medical ICU at a Tunisian University hospital. All consecutive adult patients referred for admission to ICU during 6 months were included. We collected demographic data, ICU admission/refusal reasons, co-morbidity and diagnosis at time of admission, mortality probability model (MPMII0) score, day and time of admission, request for admission and mortality at 28 days.Results327 patients were evaluated for ICU admission and 260 were refused to ICU (79.5%). Patients refused because of unavailability of beds represented 50% and patients considered “too sick to benefit” represented 22%. Multivariate analysis showed that the presence of acute respiratory failure and request by direct contact in the unit were independently associated to admission to ICU (OR: 0.15; 95% CI: 0.07-0.31 and OR: 0.16; 95% CI: 0.08-0.31, respectively). Higher mortality rates were shown in patients “too sick to benefit” (80.7%) and unavailable beds (26.56%).ConclusionRefusal of ICU admission was correlated with the severity of acute illness, lack of ICU beds and reasons for admission request. ICU clinicians should evaluate their triage decisions and, if possible, routinely solicit patient preferences during medical emergencies, taking steps to ensure that ICU admission decisions are in line with the goals of the patient. Ultimately, these efforts will help ensure that scarce ICU resources are used most effectively and efficiently.
“…Absence of acute respiratory failure and evaluation over the phone were determinants of refusal. Among recent studies, a strong effect of bed availability [ 10 ] and older age [ 16 - 18 ]. On ICU refusal was found.…”
Introductionintensive care unit (ICU) beds are a scarce resource, and admissions may require prioritization when demand exceeds supply. However, there are few data regarding both outcomes of admitted patients to intensive care unit (ICU) in comparison with outcomes of not admitted patients. The aim of this study was to assess reasons and factors associated to refusal of admission to ICU as well as the impact on mortality at 28 days and patients' outcomes.MethodsSingle-center, cross-sectional descriptive study conducted in 8-bed Medical ICU at a Tunisian University hospital. All consecutive adult patients referred for admission to ICU during 6 months were included. We collected demographic data, ICU admission/refusal reasons, co-morbidity and diagnosis at time of admission, mortality probability model (MPMII0) score, day and time of admission, request for admission and mortality at 28 days.Results327 patients were evaluated for ICU admission and 260 were refused to ICU (79.5%). Patients refused because of unavailability of beds represented 50% and patients considered “too sick to benefit” represented 22%. Multivariate analysis showed that the presence of acute respiratory failure and request by direct contact in the unit were independently associated to admission to ICU (OR: 0.15; 95% CI: 0.07-0.31 and OR: 0.16; 95% CI: 0.08-0.31, respectively). Higher mortality rates were shown in patients “too sick to benefit” (80.7%) and unavailable beds (26.56%).ConclusionRefusal of ICU admission was correlated with the severity of acute illness, lack of ICU beds and reasons for admission request. ICU clinicians should evaluate their triage decisions and, if possible, routinely solicit patient preferences during medical emergencies, taking steps to ensure that ICU admission decisions are in line with the goals of the patient. Ultimately, these efforts will help ensure that scarce ICU resources are used most effectively and efficiently.
“… Figure 2 Methodological steps from demand prediction (based on time series) to the number of intensive care unit beds (based on queue theory) for the different scenarios. ( 11 ) CER - Central Estadual de Regulação ; LOS - length of stay. …”
ObjectivesTo determine the optimal number of adult intensive care unit beds to reduce
patient's queue waiting time and to propose policy strategies.MethodsMultimethodological approach: (a) quantitative time series and queueing
theory were used to predict the demand and estimate intensive care unit beds
in different scenarios; (b) qualitative focus group and content analysis
were used to explore physicians' attitudes and provide insights into their
behaviors and belief-driven healthcare delivery changes.ResultsA total of 33,101 requests for 268 regulated intensive care unit beds in one
year resulted in 25% admissions, 55% queue abandonment and 20% deaths.
Maintaining current intensive care unit arrival and exit rates, there would
need 628 beds to ensure a maximum wait time of six hours. A reduction of the
current abandonment rates due to clinical improvement or the average
intensive care unit length of stay would decrease the number of beds to 471
and 366, respectively. If both were reduced, the number would reach 275
beds. The interviews generated 3 main themes: (1) the doctor's conflict:
fair, legal, ethical and shared priorities in the decision-making process;
(2) a failure of access: invisible queues and a lack of infrastructure; and
(3) societal drama: deterioration of public policies and health care
networks.ConclusionThe queue should be treated as a complex societal problem with a
multifactorial origin requiring integrated solutions. Improving intensive
care unit protocols and reengineering the general wards may decrease the
length of stay. It is essential to redefine and consolidate the regulatory
centers to organize the queue and provide available resources in a timely
manner, by using priority criteria, working with stakeholders to guarantee
clinical governance and network organization.
“…O elevado percentual de solicitações canceladas por alta médica ou mudança de perfil, sobretudo nas primeiras 48 horas, levanta dúvidas quanto aos motivos dessa proporção significativa de saídas da fila. Em seu estudo, Goldwasser et al (2016) observou números semelhantes e apontou a necessidade de buscar compreender se tal fenômeno se explica pela eficiência da atenção pré-hospitalar ou se por inadequação a priori dos critérios de indicação da vaga de UTI. Se, por um lado, o atendimento adequado no ambiente pré-hospitalar, mediante protocolos assistenciais, pode ser responsável pela melhora clínica e de prognóstico, evitando indicação de UTI (GOLDWASSER et al, 2016); por outro, o fluxo administrativo interno das unidades pode estar contribuindo para um processo acelerado de inserção de solicitações, podendo produzir uma demanda por UTI superestimada.…”
Section: A Upa Como Unidade De Internaçãounclassified
“…Em seu estudo, Goldwasser et al (2016) observou números semelhantes e apontou a necessidade de buscar compreender se tal fenômeno se explica pela eficiência da atenção pré-hospitalar ou se por inadequação a priori dos critérios de indicação da vaga de UTI. Se, por um lado, o atendimento adequado no ambiente pré-hospitalar, mediante protocolos assistenciais, pode ser responsável pela melhora clínica e de prognóstico, evitando indicação de UTI (GOLDWASSER et al, 2016); por outro, o fluxo administrativo interno das unidades pode estar contribuindo para um processo acelerado de inserção de solicitações, podendo produzir uma demanda por UTI superestimada. O tempo decorrido entre a inserção da solicitação de UTI e o cancelamento da mesma porque o paciente evoluiu para óbito é apresentado no gráfico 4-D. Observase que 39% dos óbitos ocorrem nas primeiras 24 horas.…”
Section: A Upa Como Unidade De Internaçãounclassified
Resumo A Rede de Urgência e Emergência (RUE) do município do Rio de Janeiro foi alvo de investimentos e reestruturação com a disseminação das Unidades de Pronto Atendimento (UPAs). Superlotação, baixa qualidade e integração comprometem a conformação dessa rede. Buscou-se analisar a organização e o funcionamento dos fluxos assistenciais estabelecidos na RUE, a partir do acesso ao leito hospitalar. Foram realizadas 36 entrevistas e análise de dados de bancos de dados primários e secundários, utilizando-se estatística descritiva e a análise exploratória. O acesso ao leito hospitalar é infrequente, sendo atendidas apenas 13% das solicitações totais. As solicitações de leito oriundas das UPAs alcançaram percentuais maiores, 40% para UTI e 36% para clínica geral. No entanto, os cerca de 60% restantes, geralmente, recebem alta ou evoluem para óbito antes de alcançar um leito hospitalar, transformando as UPAs em unidades de internação. Outro fenômeno de destaque foi a relação conflituosa entre os componentes pré-hospitalares (atenção primária e UPA) na dinâmica do fluxo do Vaga Zero, comprometendo a continuidade do cuidado. É necessário aprimorar o nível de integração entre unidades que compõem a RUE bem como expandir e qualificar a retaguarda hospitalar.
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