Watchful waiting in the ICU? Considerations for the allocation of ICU resources

The emergence of value-based health care—a reckoning of the benefits and costs of clinical and organizational interventions—has included an interest in the optimal use of critical care resources. Understanding the ideal allocation of costly and often limited resources, such as ICU beds, is essential to a hospital’s daily operation and sustainability. When faced with uncertainty about the best triage decision for a sick patient, clinicians must ask: Does this patient benefit from ICU admission? They may also ask: What is my hospital’s ICU bed availability at present? Conversely, toward the end of a patient’s ICU course, clinicians must routinely consider: Is this recovering ICU patient ready for transfer to the medical ward (i.e., does this patient no longer benefit from the ICU)? They may also, and often do, ask: Is there another patient who needs this ICU bed more?

These latter questions, related to the timing of ICU discharge, are informed by 1) a clinical assessment of “readiness for discharge” and 2) the availability of ICU and ward beds at that time. High ward occupancy is a common source of healthcare capacity strain. When present, this strain can delay both ICU discharge and, in turn, likely delay upstream new ICU admissions to those still-occupied beds. Thus, some typical ICU patients may instead be admitted to the ward or may “board” in the emergency department or in a specialty ICU that is not ideally matched with their needs. These scenarios may be associated with higher mortality relative to timely, appropriate ICU admission.

Agency for Healthcare Research and Quality