OUTLINE
• COUNTING ICU BEDS
• CONSEQUENCES OF THE “WRONG” NUMBER OF ICU BEDS
• ICU CAPACITY: A SCARCE RESOURCE RISK BENEFIT ANALYSIS
ICU BED DISTRIBUTION IN CANADA
In 2007 Manitoba had a population of 1.2 million, 118 ICU beds in 21 ICUs, for 9.8 beds
per 100,000 population
ICU BED DISTRIBUTION
12
Alberta ICU Beds Per 100000 Population
10
8
Includes CV, Neuro, Burns
General Systems
6
4
2
0
Edmonton Zone
Calgary Zone
North Zone, AB
Central Zone, AB
South Zone, AB
ICU BED DEFINITION AND DISTRIBUTION
CHALLENGES
• WHAT’S IN A NAME?
• ICU3, ICU2, ICU1, HDU, HIU, STEPDOWN, STEPUP, HIGH OBSERVATION, CLOSE OBSERVATION
• VARIABLE OPERATIONAL MODELS
•
ICU3 ONLY, COMBINED ICU3 & ICU2, COMBINED ICU/CCU, SPECIALTY CRITICAL CARE UNITS
• VARIABLE GEOGRAPHIC COVERAGE
• TRANSPLANT, SPECIALTY CRITICAL CARE, TERTIARY CRITICAL CARE
VARIATION IN ICU BED DISTRIBUTION
• IS THERE AN OPTIMAL PROVISION OF ICU BEDS FOR A GIVEN POPULATION?
• WHAT ARE THE CONSEQUENCES TO SOCIETY, IN TERMS OF BOTH RISKS AND BENEFITS, OF HAVING EITHER
VERY FEW OR MANY BEDS?
Wunsch Chest 2012
TOO FEW BEDS
• REFUSAL TO ICU
• DELAY TO ICU ADMISSION
• PREMATURE DISCHARGE
REFUSAL OF ICU ADMISSION
6%
Determine the effect of delayed ICU admission (>3 hours from
ICU acceptance) and temporary management within the
operating theatre suite on patient outcome.
• Median ICU stay was 5.1 days (delay) and 4.5 days (no-delay) (P = 0.55)
• ICU mortality was 26.8% (delay) and 24.2% (no-delay) (P = 0.47)
• ICU admission delay was associated with both an increased requirement for advanced respiratory support
(92.3% delay vs. 76.4% no-delay, P <0.01) and a longer time spent ventilated (median four days delay vs. three
days no-delay, P = 0.04).
•
•
•
Multivariate analysis demonstrated an increase in
mortality (odds ratio, 1.8; 95% CI 1.1-2.9; P = .01) with
increased duration from MET time to ICU consult for
medical patients
There was no effect of this period on ICU LOS in medical
patients
In surgical patients, the MET time to ICU consult
duration was associated with an increased ICU LOS
(coefficient, 2.1 for delay; 95% CI, 0.26-3.8; P = .02) but
had no effect on mortality.
CONSEQUENCES OF CAPACITY STRAIN
• ICU CAPACITY STRAIN ALSO NEGATIVELY IMPACTS ICU THROUGHPUT BY:
• INCREASING THE LIKELIHOOD OF PREMATURE DISCHARGE FROM ICU
• INCREASING THE RISK OF READMISSION
• INCREASING RISK OF DISCHARGE DURING OFF HOURS
• INCREASING THE INCIDENCE OF ADVERSE EVENTS INCLUDING HIGHER RISKS OF HOSPITAL ACQUIRED
INFECTIONS, LOWER HAND HYGIENE COMPLIANCE, AND HIGHER RISKS OF POSTOPERATIVE COMPLICATIONS IN
COMPLEX SURGERIES. HOWELL CURR OP IN CRIT CARE 2011
RISKS OF INCREASED ICU CAPACITY
• UNNECESSARY/INEFFICIENT USE OF INTENSIVE
CARE
• DELAYED ICU DISCHARGES
• DYING PATIENTS MAY BE MORE LIKELY TO BE
EXPOSED TO THE DISCOMFORT OF ICU
INTERVENTIONS AT END OF LIFE
• OPPORTUNITY COSTS WITHIN THE RESOURCES
RESTRICTED HEALTHCARE SYSTEM
WHAT NOW?
• “RATIONING” IS NON-TRANSPARENT, NON-RANDOM AND NEGATIVELY INFLUENCES QUALITY CARE
• IS ICU A SCARE RESOURCE?
• THE DECISIONS THAT LIMIT ACCESS TO FUNDAMENTAL AND EVEN LIFE-OR-DEATH TREATMENTS ARE FRAUGHT
WITH CONTROVERSY. THESE DECISIONS ARE DIFFICULT FOR THE MEDICAL PROVIDER TO MAKE AND ARE EVEN
MORE DIFFICULT FOR THE PATIENT TO UNDERSTAND. MEDICAL PROVIDERS ARE POORLY TRAINED TO ADDRESS
THE NUMEROUS FACTORS INVOLVED IN TRIAGE DECISIONS UNDER THE PRESSURE OF LIMITED TIME
•
REPINE MIL MED 2005