Indicators of intensive care unit capacity strain: a systematic review

Abstract

BackgroundStrained intensive care unit (ICU) capacity represents a fundamental supply-demand mismatch in ICU resources. Strain is likely to be influenced by a range of factors; however, there has been no systematic evaluation of the spectrum of measures that may indicate strain on ICU capacity.MethodsWe performed a systematic review to identify indicators of strained capacity. A comprehensive peer-reviewed search of MEDLINE, EMBASE, CINAHL, Cochrane Library, and Web of Science Core Collection was performed along with selected grey literature sources. We included studies published in English after 1990. We included studies that: (1) focused on ICU settings; (2) included description of a quality or performance measure; and (3) described strained capacity. Retrieved studies were screened, selected and extracted in duplicate. Quality was assessed using the Newcastle-Ottawa Quality Assessment Scale (NOS). Analysis was descriptive.ResultsOf 5297 studies identified in our search; 51 fulfilled eligibility. Most were cohort studies (n = 39; 76.5%), five (9.8%) were case-control, three (5.8%) were cross-sectional, two (3.9%) were modeling studies, one (2%) was a correlational study, and one (2%) was a quality improvement project. Most observational studies were high quality. Sixteen measures designed to indicate strain were identified 110 times, and classified as structure (n = 4, 25%), process (n = 7, 44%) and outcome (n = 5, 31%) indicators, respectively. The most commonly identified indicators of strain were ICU acuity (n = 21; 19.1% [process]), ICU readmission (n = 18; 16.4% [outcome]), after-hours discharge (n = 15; 13.6% [process]) and ICU census (n = 13; 11.8% [structure]). There was substantial heterogeneity in the operational definitions used to define strain indicators across studies.ConclusionsWe identified and characterized 16 indicators of strained ICU capacity across the spectrum of healthcare quality domains. Future work should aim to evaluate their implementation into practice and assess their value for evaluating strategies to mitigate strain.Systematic review registrationThis systematic review was registered at PROSPERO (March 27, 2015; CRD42015017931).Electronic supplementary materialThe online version of this article (10.1186/s13054-018-1975-3) contains supplementary material, which is available to authorized users.

Out-of-hours discharge from intensive care: certain about uncertainty

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Discharges out of hours comprise 15% of discharges from intensive care units (ICUs) to wards [1], and are usually a symptom of strained ICU capacity with demand exceeding the capacity [2]. Premature discharge of patients out of hours may cause insufficient handover and monitoring because the ward or step-down unit often have lower staffing out of hours and may lack necessary equipment for monitoring.

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“…Premature discharge of patients out of hours may cause insufficient handover and monitoring because the ward or step-down unit often have lower staffing out of hours and may lack necessary equipment for monitoring. Therefore, out-of-hours discharge is a frequently used indicator for ICU quality of care [2].In an article recently published in Intensive Care Medicine, Vollam and colleagues presented results from a well-conducted systematic review and meta-analysis examining the association between out-of-hours discharge from the ICU and readmission and hospital mortality, respectively [3]. The review and meta-analyses were thoroughly planned and the protocol was previously published [4].…”

Avaliação da demanda por leitos de Unidade de Terapia Intensiva e classificação do paciente segundo critério de prioridades: diagnóstico situacional

“…A proporção ideal de leitos de UTI/população é aquela capaz de assegurar que pacientes com potencial para se beneficiarem da internação em UTI possam ser admitidos. Entretanto, embora a abertura de novos leitos de UTI pareça a solução mais simples, poderá ser resolutiva apenas a curto prazo (REWA et al, 2018;BAGSHAW et al, 2017;ROBERT et al, 2015;RHODES;MORENO, 2012).…”

“…A oferta de leitos de cuidados intensivos não segue a mesma proporção da demanda e, a capacidade de expansão sustentável dessa complexa estrutura é relativamente limitada, visto que, o custo dessa expansão ultrapassa a dimensão do leito, por exigir investimentos consideráveis em recursos humanos, equipamentos especializados e suprimentos, de modo que as instituições de saúde possam operar de modo economicamente viável (REWA et al, 2018).…”

“…A escassez de leitos e elevada carga de trabalho dos profissionais atuantes são fatores que contribuem para essa tensão. Nesse sentido, a tensão sustentada por diversos fatores contribui para a utilização ineficiente e desigual de recursos finitos da UTI (REWA et al, 2018;BAGSHAW et al, 2018).…”