ICU Bed Availability Appears to Influence Goals of Care but not Hospital Mortality
Abstract & Commentary
By Leslie A. Hoffman, RN, PhD, Department of Acute/Tertiary Care, School of Nursing, University of Pittsburgh. Leslie A. Hoffman reports no financial relationships relevant to this field of study.
This article originally appeared in the May 2012 issue of Critical Care Alert. It was edited by David J. Pierson, MD, and peer reviewed by William Thompson, MD. Dr. Pierson is Professor Emeritus, Pulmonary and Critical Care Medicine, University of Washington, Seattle, and Dr. Thompson is Associate Professor of Medicine, University of Washington, Seattle. Drs. Pierson and Thompson report no financial relationships relevant to this field of study.
Synopsis: When fewer ICU beds were available, patients experiencing a medical emergency team call were less likely to be admitted to the ICU and more likely to have their goals of care changed.
Source: Stelfox HT, et al. Intensive care unit bed availability and outcomes for hospitalized patients with sudden clinical deterioration. Arch Intern Med 2012;172:467-474.
This study examined outcomes for 3494 adult patients who experienced clinical deterioration that triggered a medical emergency team (MET) activation over a 2-year period. The study compared ICU admission rates within 2 hours of MET activation, patient goals of care (resuscitative, medical, and comfort), and hospital mortality according to the number of ICU beds available (0, 1, 2, or > 2) after adjusting for patient characteristics (reason for admission, goals of care, comorbidities), physician characteristics (ICU attending, ICU fellow, resident or non-ICU attending), and hospital characteristics (beds available, time of week). The facilities included three Canadian hospitals (total 53 ICU beds); ICUs were closed units staffed by intensivists.
The number of MET activations averaged 3.2 per day; patients had a median age of 72 years, 47% were female, 46% had > 1 comorbidity, and 10% had a prior ICU admission during their hospital stay. The decision to admit patients to the ICU was made by the attending physician on a case-by-case basis. Reduced ICU bed availability was associated with a decreased likelihood of patient admission to the ICU within 2 hours of MET activation (P = 0.03) and an increased likelihood of a change in patient goals (P < 0.01). Patients who experienced a MET activation when zero beds were available were 33.0% (95% confidence interval [CI], -5.1% to 57.3%) less likely to be admitted to the ICU and 89.6% (95% CI, 24.9% to 188.0%) more likely to have their goals of care changed compared with days when > 2 ICU beds were available. Hospital mortality (P = 0.82) did not differ when examined in relationship to the number of ICU beds available (range, 32.1% to 34.7%). There was also no difference in post-hospital disposition defined as home with support services, home without support services, or transfer to another facility (P = 0.17).
Commentary
During the past few years, we have seen a steady increase in the number of ICU beds, driven by escalating demand for this resource. Many predict that demand will further increase in future years as a consequence of our aging population, technologic advances that expand the scope of care delivered to more fragile patients, and other factors. Findings of this study are particularly timely as they suggest approaches for resolving escalating demands for more critical care beds not related to increasing capacity. To examine decision making, the authors chose the occasion of a MET activation. Of patients who experienced a MET activation when zero ICU beds were available, 11.6% were admitted to the ICU compared to 21.4% when > 2 beds were available. More patients had their goals of care changed from resuscitative care to medical or comfort care when zero ICU beds were available (14.9%) compared to when > 2 beds were available (8.5%). These findings suggest that care options outside the ICU were sufficient to meet patient needs and/or a change in the goals of care was indicated.
Editorials on the topic of ICU resources have primarily focused on how to meet future needs for more resources rather than how to identify more appropriate use of available resources, i.e., who is the most likely to directly benefit. As the authors note, health care providers routinely make decisions about likely benefits of care but, absent those trained in disaster response, most have limited or no training in triage, making it difficult to feel comfortable identifying those who are either "too well" or "too ill" to benefit from ICU care. Studies such as the present one challenge us to critically review decision making. More studies focusing on outcomes of MET activation in regard to post care destination are needed to better define appropriate actions and related criteria for these decisions.
When fewer ICU beds were available, patients experiencing a medical emergency team call were less likely to be admitted to the ICU and more likely to have their goals of care changed.You have reached your article limit for the month. Subscribe now to access this article plus other member-only content.
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