Sustaining critical care: using evidence-based simulation to evaluate ICU management policies

Abstract

Intensive Care Units (ICU) are costly yet critical hospital departments that should be available to care for patients needing highly specialized critical care. Shortage of ICU beds in many regions of the world and the constant fire-fighting to make these beds available through various ICU management policies motivated this study. The paper discusses the application of a generic system dynamics model of emergency patient flow in a typical hospital, populated with empirical evidence found in the medical and hospital administration literature, to explore the dynamics of intended and unintended consequences of such ICU management policies under a natural disaster crisis scenario. ICU management policies that can be implemented by a single hospital on short notice, namely premature transfer from ICU, boarding in ward, and general ward admission control, along with their possible combinations, are modeled and their impact on managerial and health outcome measures are investigated. The main insight out of the study is that the general ward admission control policy outperforms the rest of ICU management policies under such crisis scenarios with regards to reducing total mortality, which is counter intuitive for hospital administrators as this policy is not very effective at alleviating the symptoms of the problem, namely high ED and ICU occupancy rates that are closely monitored by hospital management particularly in times of crisis. A multivariate sensitivity analysis on parameters with diverse range of values in the literature found the superiority of the general ward admission control to hold true in every scenario.

Boarding of Critically Ill Patients in the Emergency Department

“…An alternative approach is facilitating the timely movement of appropriate patients from the ICU to the hospital ward to create ICU bed availability. Mahmoudian-Dehkordi et al ( 56 ) evaluated a crisis surge process of prioritizing ICU patients awaiting ward transfer over ED ward admissions with the goal of opening ICU beds for critically ill ED admissions. Compared with other ICU bed management strategies tested in a crisis surge (“disaster”) model in a simulation, this strategy outperformed all others, resulting in 0.9 to 3.3 lives saved over the other scenarios (in a simulated U.S. hospital over a 3-mo period).…”

Boarding of critically Ill patients in the emergency department

“…An alternative approach is facilitating the timely movement of appropriate patients from the ICU to the hospital ward to create ICU bed availability. Mahmoudian‐Dehkordi et al 56 . evaluated a crisis surge process of prioritizing ICU patients awaiting ward transfer over ED ward admissions with the goal of opening ICU beds for critically ill ED admissions.…”

COVID-19 scenario modelling for the mitigation of capacity-dependent deaths in intensive care

“…Many simulation studies that have tackled questions around demand and capacity in healthcare, both under typical health system conditions (for example [18,19]) and in periods of increased pressure such as mass casualty events [20] and winter bed crises [21,22]. Specifically in the context of intensive care, simulation studies have addressed bed requirements by using the system dynamics simulation approach to evaluate different management policies [23], and applying analytical queuing models and simulations to the management of patient flow [24,25]. For a general guide of how simulation modelling may be used in responding to the challenges of COVID-19, refer to [26].…”