Rationing Intensive Care — Physician Responses to a Resource Shortage

Abstract

To determine how physicians ration limited critical resources, we studied the allocation of intensive-care-unit (ICU) beds during a shortage caused by a lack of nurses. As the bed capacity of the medical ICU decreased from 18 to 8, the percentage of days on which one or more beds were available decreased from 95 to 55 per cent, and monthly admissions decreased from 122 to 95. Physicians responded by restricting ICU admissions to acutely ill patients and reducing the proportion of patients admitted primarily for monitoring. Among patients admitted because of chest pain, the proportion actually sustaining a myocardial infarction increased linearly with the restriction in bed capacity. Although more patients with myocardial infarction were admitted to non-intensive-care areas, there was no increase in mortality. In addition, physicians transferred patients out of the ICU sooner. There was no apparent withdrawal of care from dying patients. Our results suggest that physicians can respond to moderate resource limitations by more efficient use of intensive-care resources.

Access to intensive care unit beds for neurosurgery patients: a qualitative case study

“…Though there is a substantial literature on resource allocation and utilisation in ICUs including the assessment and predictors of outcome, [1][2][3][4][5][6][7][8][9][10][11][12] and guidelines for triage of critically ill patients and ICU admissions and discharges, 11 13 we are unaware of any research that describes actual priority setting in an ICU with particular reference to neurosurgery patients.…”

The Allocation of Intensivists’ Rounding Time under Conditions of Intensive Care Unit Capacity Strain

“…Exogenous sources of variability identified thus far include variable blood volume in the QFT TB antigen tube, variable vigor of tube shaking, and processing delay (2). Endogenous immunomodulators originating from the host remain unknown.…”

“…With rising demand for critical care, intensivists' time must increasingly be divided among patients (1)(2)(3)(4)(5)(6). Recent studies suggest that increased strain at intensive care unit (ICU) admission leads to higher mortality in closed ICUs (7) and that increased strain at discharge leads to increases in ICU readmissions (8).…”

The Relationship Between ICU Bed Availability, ICU Readmission And Cardiac Arrest On The General Wards

“…A large study of the APACHE database demonstrated no association between bed availability and ICU mortality (3). However, decreased ICU bed availability has been shown to be associated with increased severity of illness in patients admitted to the ICU (4), (5), (6), suggesting that bed availability plays a role in triage decisions. Some studies have demonstrated a shorter ICU length of stay associated with limited bed availability, which may indicate increased pressure to discharge patients when beds are limited (3), (5), (6).…”

“…However, decreased ICU bed availability has been shown to be associated with increased severity of illness in patients admitted to the ICU (4), (5), (6), suggesting that bed availability plays a role in triage decisions. Some studies have demonstrated a shorter ICU length of stay associated with limited bed availability, which may indicate increased pressure to discharge patients when beds are limited (3), (5), (6). Finally, one study of a neurological ICU demonstrated an association between increased patient flow rates and increased rates of readmission to the ICU (7).…”