Stepdown beds provide an intermediate level of care for patients with requirements somewhere between that of the general ward and the intensive care unit. Models of care include incorporation of stepdown beds into intensive care units, stand-alone units, or incorporation of beds into standard wards. Stepdown beds may be used to provide a higher level of care for patients deteriorating on a ward ("step-up"), a lower level of care for patients transitioning out of intensive care ("stepdown") or a lateral transfer of care from a recovery room for postoperative patients. These units are one possible strategy to improve critical care cost-effectiveness and patient flow without compromising quality, but these potential benefits remain primarily theoretical as few patient-level studies provide concrete evidence. This narrative review provides a general overview of the theory of stepdown beds in the care of hospitalized patients and a summary of what is known about their impact on patient flow and outcomes and highlights areas for future research.

BackgroundTraumatic injury is a leading cause of morbidity and mortality worldwide, but epidemiologic data about trauma patients who require intensive care unit (ICU) admission are scant. This study aimed to describe the annual incidence of ICU admission for adult trauma patients, including an assessment of risk factors for hospital complications and mortality in this population.MethodsThis was a retrospective study of adults hospitalized at Level 1 and Level 2 trauma centers after trauma and recorded in the National Trauma Data Bank in 2013. Multiple logistic regression analyses were performed to determine predictors of hospital complications and hospital mortality for those who required ICU admission.ResultsThere were an estimated total of 1.03 million ICU admissions for trauma at Level 1 and Level 2 trauma centers in the United States in 2013, yielding an annual incidence of 3.3 per 1000 population. The annual incidence was highest in men (4.6 versus 1.9 per 100,000 for women), those aged 80 years or older (7.8 versus 3.6–4.3 per 100,000 in other age groups), and residents in the Western US Census region (3.9 versus 2.7 to 3.6 per 100,000 in other regions). The most common complications in patients admitted to the ICU were pneumonia (10.9 %), urinary tract infection (4.7 %), and acute respiratory distress syndrome (4.4 %). Hospital mortality was significantly higher for ICU patients who developed one or more complications (16.9 % versus 10.7 % for those who did not develop any complications, p < 0.001).ConclusionsAdmission to the ICU after traumatic injury is common, and almost a quarter of these patients experience hospital complications. Hospital complications are associated with significantly increased risk of mortality.Electronic supplementary materialThe online version of this article (doi:10.1186/s40621-016-0084-5) contains supplementary material, which is available to authorized users.

Purpose of review Interest in international comparisons of critical illness is growing, but the utility of these studies is questionable. This review examines the challenges of international comparisons and highlights areas where international data provide information relevant to clinical practice and resource allocation. Recent findings International comparisons of ICU resources demonstrate that definitions of critical illness and Intensive Care Unit (ICU) beds vary due to differences in ability to provide organ support and variable staffing. Despite these limitations, recent international data provide key information to understand the pros and cons of different availability of ICU beds on patient flow and outcomes, and also highlight the need to ensure long-term follow-up due to heterogeneity in discharge practices for critically ill patients. With increasing emphasis on curbing costs of healthcare, systems that deliver lower cost care provide data on alternative options, such as regionalization, flexible allocation of beds, and bed rationing. Summary Differences in provision of critical care can be leveraged to inform decisions on allocation of ICU beds, improve interpretation of clinical outcomes, and assess ways to decrease costs of care. International definitions of key components of critical care are needed to facilitate research and ensure rigorous comparisons.

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Background: Antiretroviral therapy (ART) scale-up in resource-limited countries, with limited capacity for CD4 and HIV viral load monitoring, presents a unique challenge. We determined the effectiveness of first-line ART in a real world pediatric HIV clinic and explored associations between readily obtainable patient data and the trajectories of change in CD4 count and HIV viral load. Methods: We performed a longitudinal study of a cohort of HIV-infected children initiating ART at the Korle-Bu Teaching Hospital Pediatric HIV clinic in Accra, Ghana, aged 0-13 years from 2009-2012. CD4 and viral load testing were done every 4 to 6 months and genotypic resistance testing was performed for children failing therapy. A mixed linear modeling approach, combining fixed and random subject effects, was employed for data analysis.