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Is ICU triage more efficient under strain?

By 2020, the expected number of individuals 65 years or older is projected to rise by approximately 50%, according to the Society of Critical Care Medicine. Along with this growth, the number of patients requiring critical care is likely to rise and the number of critical care providers likely to shrink, creating situations in which ICUs will increasingly operate under strained conditions.

To study whether these resource-strapped ICUs will negatively impact patient care, researchers out of Penn State analyzed more than 200,000 patients from 155 U.S. ICUs from 2001 to 2008. ICU capacity was measured by ICU census, number of new admissions, and the average acuity of the other patients in the ICU at the time of a patient’s discharge.

What they found was surprising. The Penn State researchers found that when the ICUs were at their busiest, patients were discharged earlier than normal, 6.3 hours earlier to be exact.

With such a difference in triage times, researchers became concerned that this finding would increase overall length of stay and the odds of dying in the hospital. But no increase was found.

“Many believe there will be a break at the intersection of the growing demand and our ability to supply high-value critical care. So we asked the question: When busy, do critical care providers discharge patients quicker than they otherwise would and does it result in negative consequences such as rationing critical care resources or promoting breakdowns in the quality of patient handoffs among providers?” said Jason Wagner, MD, MSHP, a senior fellow in the Division of Pulmonary, Allergy and Critical Care at the Perelman School of Medicine, University of Pennsylvania. “We found that patients are discharged earlier but are no worse off — which suggests that in a strained-resource setting, doctors are more efficiently discharging patients into the appropriate next step of care. This rightfully frees up critical care providers and beds for any potential incoming patients.”

What was noted was that ICU providers are more likely to keep patients longer when they are not busy; whereas, when under strain, patients’ needs for ICU-level care are examined more closely and patients are transferred outside the ICU for care, when appropriate.

“Although the reductions in ICU length of stay during times of strain were modest, focusing efforts on achieving similar reductions in ICU length of stay for majority of patients admitted to the nearly 100,000 ICU beds in the United States could reduce the overall use of critical care in the country,” said Dr. Wagner. “Rather than reflexively moving towards the higher cost approach of adding more ICU beds, perhaps more effort should be focused on increasing the efficiency with which we provide critical care services with our existing resources.”