Lena M. Chen, M.D., Edward H. Kennedy, M.S., Anne Sales, Ph.D., R.N., and Timothy P. Hofer, M.D. January 30, 2013.
The patient had not yet coded but was spiraling downward, prompting a request for a bed in the intensive care unit (ICU). But the ICU had no available beds. Hours passed before the decision was made that another patient could safely be “bumped” out of the unit to accommodate our patient…
After the transfer, in the empty room strewn with unused bottles, procedure kits, and hospital gowns, there was a moment of peaceful quiet but weariness. The team was exhausted from worrying that the patient would code before being transferred to the ICU, from running a makeshift ICU on a floor not equipped for it, and from knowing that other patients had been neglected in the interim. This was not the first time that such a sequence of events had occurred — or the last time it would. Might things be done differently?
Just over half a century ago, hospitals opened ICUs with the explicit purpose of caring for the sickest patients, using the newest technology. Today, critical care in the United States costs more than $80 billion annually. About one in five Americans will die during a hospitalization that includes time spent in an ICU, and many more will use critical care services. With an aging population and ever-growing demand for critical care, some observers worry that the number of staffed ICU beds will become increasingly inadequate. In 2010, the Leapfrog Group found that nearly two thirds of surveyed hospitals did not meet standards for physician staffing in the ICU.1
In response to the shortage of intensivists, numerous strategies have been proposed. These include remote ICU telemonitoring and — as was recently recommended by the Society of Critical Care Medicine and the Society of Hospital Medicine — the critical care certification of hospitalists. Congress has taken notice as well: members proposed a bill (H.R. 971) to direct the Institute of Medicine and the Comptroller General to examine the effectiveness of ICU care and the supply of critical care physicians and beds.
Nevertheless, relatively little effort has been devoted to what could be the most promising approach to the problem: the application of advances in health information technology (HIT) to triage decisions. A few integrated health care systems such as the Veterans Affairs (VA) Healthcare System and Kaiser Permanente Northern California have already drawn on the ability of electronic health records (EHRs) to generate reliable estimates of the risk of death within 30 days for every patient on admission. Yet these calculations of risk, which may combine real-time data on laboratory results, demographics, coexisting conditions, and vital signs, are not being used to inform decisions about admission to the ICU. To accelerate progress in this area, we believe that more targeted incentives for meaningful use of HIT should be considered.
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