Slashing costs may not be way to manage ICU care

High-risk patients do poorly under low staffing

The way your ICU is organized and dispenses medical care to patients can significantly affect mortality rates, cost of care to insurers, and the length of time a high-risk patient stays in the unit. From daily rounds performed by a full-time ICU physician to routine extubation of patients in the operating room, an ICU’s organizational characteristics can have important effects on outcomes, some clinicians argue.

The idea may seem obvious to nurse managers, but a group of critical care clinicians at the Johns Hopkins University School of Medicine in Baltimore tested the notion and found a close correlation between factors such as nurse and physician staffing levels and length of patient stay.

The findings could have widespread implications as ICUs attempt to cut back on staffing and other resources as a cost-saving measure. "The information can provide some direction for clinicians and hospital administrators regarding ways they can further improve outcomes for patients who have high-risk operations," says Peter J. Pronovost, MD, a researcher in the department of anesthesia and critical care medicine at Johns Hopkins.

Using discharge data for patients admitted for abdominal aortic surgery at all Maryland hospitals, Pronovost and his team found that units not having daily rounds by a full-time staff intensivist were likely to see a threefold increase in in-hospital mortality.

They also saw an increased risk of patient cardiac arrest, renal failure, septicemia, platelet transfusion, and repeat reintubations. Cases of abdominal aortic surgery were chosen because they reflect a common yet high-risk procedure performed in a variety of acute-care hospitals with different organizational characteristics, Provonost says. The data was adjusted for comorbidity and severity of illness.1

Among other characteristics related to higher mortality and morbidity were: 1) an ICU nurse/patient ratio of less than 2:1; 2) inconsistent monthly reviews of unit mortality and morbidity data; and 3) routine extubation in the operating room, rather than based on careful assessment.

However, Provonost and his team called for further study before implementing specific measures to improve post-surgical ICU care.


1. Provonost PJ, Jenckes MW, Dorman T, et al. Organizational characteristics of intensive care units related to outcomes of abdominal aortic surgery. JAMA 1999; 281:1,310-1,317.