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EDITORIAL
Year : 2022  |  Volume : 12  |  Issue : 3  |  Page : 119-120

What's new in critical illness and injury science? Resource allocation and very short intensive care unit stays


Department of Emergency Medicine, Alton Memorial Hospital, Alton, IL, USA

Date of Submission09-Sep-2022
Date of Acceptance09-Sep-2022
Date of Web Publication20-Sep-2022

Correspondence Address:
Dr. Andrew C Miller
Department of Emergency Medicine, Alton Memorial Hospital, 1 Memorial Dr, Alton, IL 62002
USA
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ijciis.ijciis_61_22

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How to cite this article:
Miller AC. What's new in critical illness and injury science? Resource allocation and very short intensive care unit stays. Int J Crit Illn Inj Sci 2022;12:119-20

How to cite this URL:
Miller AC. What's new in critical illness and injury science? Resource allocation and very short intensive care unit stays. Int J Crit Illn Inj Sci [serial online] 2022 [cited 2022 Nov 30];12:119-20. Available from: https://www.ijciis.org/text.asp?2022/12/3/119/356356



Appropriate and optimal allocation of limited resources remains a concern for intensive care units (ICU). Early appropriate referral of patients to an ICU can significantly reduce morbidity and mortality.[1],[2],[3],[4] One great challenge of critical care has been to accurately identify those patients who would (and would not) benefit from the resources available in an ICU setting to optimize resource utilization and delivery of care. In many settings, the requests for ICU beds surpass availability. Improper or inefficient selection of patients for ICU beds may block others from benefiting from this resource and may have ripple effects that adversely impact the hospital dynamics of the larger health-care system. Beyond blocking other admissions from within the hospital or from the emergency department, inefficient bed, and resource utilization may even compromise patients at other hospitals by blocking transfer of patients requiring a higher level of care than is offered at their current locale. In addition, lack of available beds may result in the cancellation of scheduled elective surgeries that require postoperative ICU monitoring with additional downstream consequences including higher idle operating room time, underutilization of personnel, and prolongation of waiting lists.[5] These delays in care may further expose patients to unnecessary morbidity or mortality.

Whereas considerable research has assessed long-stay patients, evidence regarding short-stay patients is lacking. Studies report that up to one-third of ICU admissions are short-stay.[5],[6] There are many challenges when studying the short ICU stay population. Foremost is defining the parameters of what signifies a short stay, as studies range from <24 h to <8 days.[5],[6],[7],[8],[9],[10] Moreover, this population is composed of a heterogeneous patient mix, and they are often excluded from outcome studies.[5] This group includes both low-risk (e.g., postoperative monitoring) and high-risk patients, many of whom do not survive their ICU stay.[5] Nearly 30% of the short-stay patients have a 1-day overall hospital length-of-stay.[6] Some of this is because of younger patients with a lower risk of death admitted for postoperative monitoring,[7] but also contributing are due to futile high acuity cases with poor prognosis and no meaningful hope of recovery who are identified by intensivists and designated with a do not resuscitate (DNR) status (often within hours of admission).[5] For both sets of patients, one may consider whether the ICU was the optimal location for their care. For example, routine lower-risk postoperative patients wh.,o are unlikely to require any ICU-specific interventions (e.g., mechanical ventilation), may conceivably be cared for by an appropriately trained intermediate care unit.[7] Alternatively, for higher acuity or futile cases, providers may be more aggressive about discussing goals of care with patients, their families, and surrogates to more rapidly identify those very high acuity patients who opt for DNR status, or for whom life-supporting measures will be withdrawn, or goals of care transitioned to comfort measures. The goals of care for such patients may similarly be accomplished outside of an ICU setting. The timing of writing DNR orders has been associated with shortening needed hospital and ICU care, as well as affecting significant reductions in resources utilized,[11] and systems may benefit from earlier discussions thereby allowing them to maintain patient dignity and meet expectations and goals of care while utilizing hospital resources more efficiently.

In this issue of the International Journal of Critical Illness and Injury Science, Pandit et al.[12] assessed the characteristics and outcomes of short-stay (<24 h) ICU patients at a tertiary care academic medical center in the United States. Their work highlights that despite the patient's lower illness severity and fewer ICU-level care needs, short-stay patients spend an equally substantial amount of time occupying an ICU bed while waiting for a floor bed as nonshort-stay patients. This further highlights the importance of ICU triage assessments and raises questions for opportunities for improved resource allocation and throughput. Examples may include the generation of short-stay units, more aggressive clarification of goals of care and DNR status before ICU transfer, and logistical and operations approaches to speed bed turnaround times when a patient is ready for ICU (or hospital) discharge.

Research quality and ethics statement

This report was exempt from the requirement of approval by the Institutional Review Board/Ethics Committee. The authors followed applicable EQUATOR Network (http://www.equator-network.org/) guidelines, however, no specific guideline is available for editorials.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
   References Top

1.
Metcalfe MA, Sloggett A, McPherson K. Mortality among appropriately referred patients refused admission to intensive-care units. Lancet 1997;350:7-11.  Back to cited text no. 1
    
2.
Joynt GM, Gomersall CD, Tan P, Lee A, Cheng CA, Wong EL. Prospective evaluation of patients refused admission to an intensive care unit: Triage, futility and outcome. Intensive Care Med 2001;27:1459-65.  Back to cited text no. 2
    
3.
Sprung CL, Geber D, Eidelman LA, Baras M, Pizov R, Nimrod A, et al. Evaluation of triage decisions for intensive care admission. Crit Care Med 1999;27:1073-9.  Back to cited text no. 3
    
4.
Edbrooke DL, Minelli C, Mills GH, Iapichino G, Pezzi A, Corbella D, et al. Implications of ICU triage decisions on patient mortality: A cost-effectiveness analysis. Crit Care 2011;15:R56.  Back to cited text no. 4
    
5.
Arabi Y, Venkatesh S, Haddad S, Al Malik S, Al Shimemeri A. The characteristics of very short stay ICU admissions and implications for optimizing ICU resource utilization: The Saudi experience. Int J Qual Health Care 2004;16:149-55.  Back to cited text no. 5
    
6.
Chidi OO, Perman SM, Ginde AA. Characteristics of short-stay critical care admissions from emergency departments in Maryland. Acad Emerg Med 2017;24:1204-11.  Back to cited text no. 6
    
7.
Sedaghat Siyahkal M, Khatami F. Short stay in general intensive care units: Is it always necessary? Med J Islam Repub Iran 2014;28:143.  Back to cited text no. 7
    
8.
Zhou VL, Shofer FS, Desai NG, Adler DH, Greenwood JC. Third place: Predictors of short ICU length of stay for patients presenting with diabetic ketoacidosis. J Emerg Med 2018;54:570.  Back to cited text no. 8
    
9.
Stricker K, Rothen HU, Takala J. Resource use in the ICU: Short-versus long-term patients. Acta Anaesthesiol Scand 2003;47:508-15.  Back to cited text no. 9
    
10.
Hermans G, Van Aerde N, Meersseman P, Van Mechelen H, Debaveye Y, Wilmer A, et al. Five-year mortality and morbidity impact of prolonged versus brief ICU stay: A propensity score matched cohort study. Thorax 2019;74:1037-45.  Back to cited text no. 10
    
11.
Rapoport J, Teres D, Lemeshow S. Resource use implications of do not resuscitate orders for intensive care unit patients. Am J Respir Crit Care Med 1996;153:185-90.  Back to cited text no. 11
    
12.
Pandit PN, Mallozzi M, Mohammed R, McDonough G, Treacy T, Zahustecher N, et al. A retrospective cohort study of short-stay admissions to the medical intensive care unit: Defining patient characteristics and critical care resource utilization. Int J Crit Ill Inj Sci 2022;12:127-32.  Back to cited text no. 12
    




 

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