Abbreviation: IQR, interquartile range.
a Data are presented as No. (%) except where noted.
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Chang DW, Dacosta D, Shapiro MF. Priority Levels in Medical Intensive Care at an Academic Public Hospital. JAMA Intern Med. 2017;177(2):280–281. doi:10.1001/jamainternmed.2016.8060
Critical care services can be life-saving, but many patients admitted to intensive care units (ICUs) are too sick or, conversely, not sick enough to benefit.1,2 Intensive care unit overutilization can produce more costly and invasive care without improving outcomes.3,4 Guidelines from the Society of Critical Care Medicine (SCCM) prioritize patients for ICU admission based on projected likelihood of benefit (from highest to lowest priority) as follows5: priority 1: critically ill, needing intensive treatment and monitoring that cannot be provided outside of ICUs; priority 2: not critically ill, but requiring close monitoring and potentially immediate intervention; priority 3: critically ill, but reduced likelihood of recovery because of underlying diseases or severity of acute illness; and priority 4: not appropriate for ICU; equivalent outcomes achievable with non-ICU care based on low risk of clinical deterioration, presence of irreversible illness, or imminent death.
This study determined the proportion of medical ICU patients in each priority group within a tertiary care academic public hospital.
We prospectively studied all patients admitted to the medical ICU from July 1, 2015, to June 15, 2016 (n = 808). The study was approved as an exempt protocol by the institutional review board at Los Angeles Biomedical Research Institute. Medical records were reviewed by the ICU director (D.W.C.) each day. Reasons for ICU admission and ongoing ICU needs were evaluated and assigned priority ranks according to SCCM guidelines (priority 1-4). Because needs for ICU care may change, each ICU day was ranked using the same priority categories but adding a fifth category for patients awaiting transfer out of the ICU to examine the distribution of patient-days at each priority level. We categorized patients needing close monitoring but otherwise receiving care that could be provided outside of the ICU as priority 2, and patients with limited life expectancy or poor prospects for meaningful functional recovery as priority 3. When priority ranks were uncertain from medical record review, ICU physicians (attending or fellow) adjudicated (19.9% of cases). A random subsample of 80 medical records was re-reviewed by a coinvestigator (D.D.) blinded to the study hypothesis and priority ranks assigned; concordance in priority ranks was 85.0%.
Of 808 medical ICU admissions, 46.9% were categorized as priority 1, 23.4% as priority 2, 20.9% as priority 3, and 8.8% as priority 4 (Table). Patient characteristics, comorbidities, severity of illness, and primary ICU diagnoses are shown in the Table. Intensive care unit and hospital mortality rates were 13.4% and 19.6%, respectively, for priority 1, 4.2% and 10.6% for priority 2, 47.3% and 61.9% for priority 3, and 2.8% and 7.0% for priority 4 (Table); 56.0% of priority 1 patients and 62.4% of priority 2 patients were discharged home compared with 6.0% of priority 3 patients (Table). Of 3794 patient-days, 35.2% were assigned priority 1; 25.3%, priority 2; 27.5%, priority 3; 3.3%, priority 4; and 8.7%, priority 5.
Over 50% of patients admitted to the ICU had priority ranks suggesting that they were potentially either too well (priority 2) or too sick (priority 3) to benefit from ICU care or could have received equivalent care in non-ICU settings (priority 4). Nearly 65% of total ICU days were allocated to care that was considered discretionary monitoring (priority 2), low likelihood of benefit despite critically illness (priority 3), or manageable in non-ICU settings (priority 4 and 5). Our findings suggest that ICU care is inefficient, devoting substantial resources to patients less likely to benefit.6 Determining appropriateness of ICU care is complex; in addition to expected benefit, it must incorporate patient preferences, availability of ICU resources, and levels of medical complexity manageable in non-ICU settings. As such, our study cannot fully differentiate between appropriate and inappropriate care. However, appropriateness of ICU care for patients previously in good health but with poor prognoses from acute illness is likely different than those whose expected benefit from ICU care is low from progressive irreversible medical comorbidities. In our study, 26.0% of priority 3 patients had advanced malignant neoplasms and 27.2% had advanced dementia, suggesting that many patients in this priority group were at risk for receiving inappropriate ICU care. This was a single-hospital study; results may differ at other institutions. However, categorizing ICU admissions by priority ranks identified opportunities to improve allocation of ICU resources at our institution. Other hospitals could use this approach to improve the efficiency of their ICU utilization.
Corresponding Author: Dong W. Chang, MD, MS, Department of Medicine, Harbor-UCLA Medical Center, Box 405, 1000 W Carson St, Torrance, CA 90509 (email@example.com).
Published Online: December 27, 2016. doi:10.1001/jamainternmed.2016.8060
Author Contributions: Dr Chang had full access to all of the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis.
Concept and design: Chang, Shapiro.
Acquisition, analysis, or interpretation of data: All authors.
Drafting of the manuscript: Chang.
Critical revision of the manuscript for important intellectual content: All authors.
Statistical analysis: Chang.
Administrative, technical, or material support: Chang.
Conflict of Interest Disclosures: None reported.
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