Potentially Avoidable Surgical Intensive Care Unit Admissions and Disposition Delays

Dhillon, Navpreet K.; Ko, Ara; Smith, Eric; Kharabi, Mayumi; Castongia, Joseph; Nurok, Michael; Gewertz, Bruce L.; Ley, Eric J.

doi:10.1001/jamasurg.2017.2165

Cited by 14 publications

(10 citation statements)

References 33 publications

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“…We submit this indicator of strain can be readily measured at the ICU level as “avoidable-days”, defined as the proportion of total ICU stay (and cumulative patient-days) accounted for by avoidable delay in ICU discharge. [ 16 , 17 ] Avoidable delays in ICU discharge may have negative implications for care processes and outcomes for patients. [ 18 ] Avoidable-days, as a key performance indicator, can be used to identify operational inefficiencies and target quality improvement initiatives.…”

Section: Discussionmentioning

confidence: 99%

Perspectives on strained intensive care unit capacity: A survey of critical care professionals

et al. 2018

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BackgroundStrained intensive care unit (ICU) capacity represents a supply-demand mismatch in ICU care. Limited data have explored health care worker (HCW) perceptions of strain.MethodsCross-sectional survey of HCW across 16 Alberta ICUs. A web-based questionnaire captured data on demographics, strain definition, and sources, impact and strategies for management.Results658 HCW responded (33%; 95%CI, 32–36%), of which 452 were nurses (69%), 128 allied health (19%), 45 physicians (7%) and 33 administrators (5%). Participants (agreed/strongly agreed: 94%) reported that strain was best defined as “a time-varying imbalance between the supply of available beds, staff and/or resources and the demand to provide high-quality care for patients who may become or who are critically ill”; while some recommended defining “high-quality care”, integrating “safety”, and families in the definition. Participants reported significant contributors to strain were: “inability to discharge ICU patients due to lack of available ward beds” (97%); “increases in the volume” (89%); and “acuity and complexity of patients requiring ICU support” (88%). Strain was perceived to “increase stress levels in health care providers” (98%); and “burnout in health care providers” (96%). The highest ranked strategies were: “have more consistent and better goals-of-care conversations with patients/families outside of ICU” (95%); and “increase non-acute care beds” (92%).InterpretationStrain is perceived as common. HCW believe precipitants represent a mix of patient-related and operational factors. Strain is thought to have negative implications for quality of care, HCW well-being and workplace environment. Most indicated strategies “outside” of ICU settings were priorities for managing strain.

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Section: Discussionmentioning

confidence: 99%

Perspectives on strained intensive care unit capacity: A survey of critical care professionals

et al. 2018

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“…Similar interventions could be applied within the VA. At another small urban U.S. academic center hospital, the authors described interventions to help avoid inappropriate surgical intensive care unit (ICU) admissions. These interventions included the development of admission guidelines, improved handoff communication, earlier end-of-life conversations, and appropriate disposition of acute patients, which could also be applied in the VA setting (Dhillon et al, 2017).…”

Section: Resultsmentioning

confidence: 99%

Level of Care Appropriateness in VA Inpatient Surgery Cases

Neugaard

Politi

McCay

2023

Professional Case Management

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Purpose of Study: Within the Veterans Health Administration, utilization management (UM) focuses on reducing unnecessary or inappropriate hospitalizations by applying evidence-based criteria to evaluate whether the patient is placed in the right level of care. This study examined inpatient surgery cases to classify reasons for not meeting criteria and to identify the appropriate level of care for admissions and subsequent bed days of care. Primary Practice Settings: There were 129 VA Medical Centers in which inpatient UM reviews were performed during that time, of which 109 facilities had UM reviews conducted in Surgery Service. Methodology and Sample: All admissions to surgery service during fiscal year 2019 (October 1, 2018 to September 30, 2019) that had a UM review entered in the national database were extracted, including current level of care, recommended level of care, and reasons for not meeting criteria. The following demographic and diagnostic fields were supplemented from a national data warehouse: age, gender, marital status, race, ethnicity, and service connection status. Data were analyzed with descriptive statistics. Characteristics of patient demographics were compared using the χ2 test for categorical variables and the Student's t test. Results: A total of 363,963 reviews met conditions to be included in the study: 87,755 surgical admission reviews and 276,208 continued stay reviews. There were 71,274 admission reviews (81.22%) and 198,521 (71.87%) continued stay reviews that met the InterQual criteria. The primary reason for not meeting admission criteria was clinical variance (27.70%), followed by inappropriate level of care (26.85%). The leading reason for not meeting continued stay criteria was inappropriate level of care (27.81%), followed by clinical instability (25.67%). Of the admission reviews not meeting admission criteria, 64.89% were in the wrong level of care and 64.05% of continued stay reviews were also in the wrong level of care. Half of the admission reviews not meeting criteria had a recommended level of care as home/outpatient (43.51%), whereas nearly one-third (28.81%) continued stay reviews showed a recommended level of care of custodial care or skilled nursing. Implications for Case Management Practice: This study identified system inefficiencies through admission and continued stay reviews of surgical inpatients. Patients admitted for ambulatory surgery or for preoperative testing prior to day of surgery resulted in avoidable bed days of care that may have contributed to patient flow issues and limited the available hospital beds for other patients. Through early collaboration with case management and care coordination professionals, alternatives can be explored that safely address the patient needs, such as temporary lodging options. There may be conditions or complications that can be anticipated on the basis of patient history. Proactive efforts to address these conditions may help avoid unnecessary bed days and extended lengths of stay.

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“…4 Both the pediatric and adult literature identify operational contributors to delayed transfer out of the ICU, including appropriate bed availability and poor communication between medical teams. 1,[4][5][6][7][8][9][10][11][12] Prior improvement work has targeted these downstream, operations-related drivers of a delayed transfer. [4][5][6]8,11,12 However, identifying patients as medically ready for transfer is a critical component that has received less attention.Viral bronchiolitis is one of the most common reasons for Pediatric ICU (PICU) admission.…”

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confidence: 99%

Reducing PICU-to-Floor Time-to-Transfer Decision in Critically Ill Bronchiolitis Patients using Quality Improvement Methodology

Fritz

Martin

Riccolo

et al. 2022

Pediatric Quality &Amp; Safety

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Potentially Avoidable Surgical Intensive Care Unit Admissions and Disposition Delays

Abstract: Nearly one-fourth of SICU days could be categorized as potentially avoidable. Targeted interventions resulted in a significant reduction of potentially avoidable SICU days.

Cited by 14 publications

References 33 publications

Perspectives on strained intensive care unit capacity: A survey of critical care professionals

Perspectives on strained intensive care unit capacity: A survey of critical care professionals

Level of Care Appropriateness in VA Inpatient Surgery Cases

Reducing PICU-to-Floor Time-to-Transfer Decision in Critically Ill Bronchiolitis Patients using Quality Improvement Methodology

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