Intensive Care Units Do Better Under Pressure, Study Finds

A new study shows critical care providers treat patients more effectively when put under pressure.

Intensive Care Unit director Dr. Yugan Mudaliar tends to ICU patient Christine Henderson at Westmead Hospital on March 12, 2007, in Sydney, Australia.
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When intensive care units are busier and under more pressure, doctors discharge patients more quickly than normal, but without negatively affecting their outcomes, according to a new study from the University of Pennsylvania.

"We wanted to look at whether or not discharge practices influenced outcomes," says lead researcher Jason Wagner, a senior fellow at the university's Perelman School of Medicine.

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The existing body of research had only observed single centers or accounted for one measure of strain and showed mixed results: some suggest discharging patients more quickly can lead to adverse outcomes from the withholding of critical care, while other studies suggest the pressure would increase efficiency. Lead researcher Jason Wagner says his team found the opposite.

Wagner and his team found that when ICUs were at their busiest, patients were discharged to other parts of the hospital approximately 6.3 hours sooner, and had no greater chance of dying in the hospital and no decrease in their chances of going home. The researchers analyzed data from more than 200,000 patients from 155 ICUs between 2001 and 2008 – the largest and most comprehensive study to date, according to Wagner.

"I think that our study provides some evidence to suggest that when providers are not busy, they keep patients in the ICU for longer than is necessary - suggesting that when there is an excess of critical care resources ... we have a tendency to provide what is likely to be more low-value extensions of ICU stays," Wagner says.

The team also measured an ICU's capacity strain based on three different factors: the number of patients who spent at least two hours in the ICU that day (the ICU census), the number of new admissions that day (the ICU flow), and the average severity of illness of the people in the ICU. When all three of those measures were strained, the length of a patient's stay in the ICU decreased. Additionally, none were associated with higher odds of ICU mortality or lower odds of being discharged from the hospital to home, Wagner says.

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"Getting people out of the ICU setting as quickly as is safely possible serves the best interest of both individual patients and society," Wagner says. "ICUs are frightening places for many patients and families ... Keeping patients in this setting for longer than is needed is not in line with high-quality patient-centered care."

The study's results show that when critical care providers are not busy, they may keep patients in the ICU longer than is necessary, increasing the likelihood that those resources will not be available for patients in more critical conditions, Wagner says. More research to better identify which patients need to be treated in ICUs and which could be safely treated elsewhere would be beneficial, he added.

"There are likely large numbers of patients currently existing in U.S. ICUs right now who are too well to benefit from ICU care," Wagner says. "To withhold critical care when it is not needed isn't rationing - it's more a reflection of efficiency - which is one of the Institute of Medicine's pillars of high-quality care."

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