International Journal for Quality in Health Care 16:149-155 (2004)
International Journal for Quality in Health Care vol. 16 no. 2 © International Society for Quality in Health Care and Oxford University Press 2004; all rights reserved
The characteristics of very short stay ICU admissions and implications for optimizing ICU resource utilization: the Saudi experience
1 Department of Intensive Care and
3 Quality Management,
2 King Fahad National Guard Hospital, Riyadh, Kingdom of Saudi Arabia
Objective. Patients with very short stays (<24 hours) in intensive care units (ICUs) constitute a distinct group with a high turnover rate and a unique patient mix. Our aim was to study their characteristics with the aim of developing strategic approaches for better and more appropriate utilization of ICU resources.
Design. Prospective cohort study.
Setting. Adult medical/surgical ICU in a tertiary care teaching hospital.
Study participants. All admissions in an adult ICU from March 1999 to February 2001 and staying <24 hours were enrolled. Relevant data were collected on these patients, their course and outcome, and analyzed after categorizing patients according to: (i) the nature of admission; and (ii) risk of death (ROD) estimated by Mortality Probability Model II0.
Results. Patients staying <24 hours (n = 304) formed 27.8% of all ICU admissions, with an ICU mortality rate of 26.3%. Only 45.4% of them utilized ICU-specific procedures. Around one-third (32.6%) were elective admissions comprising younger patients, with a significantly lower prevalence of chronic illness, a lower ROD, and utilization of less ICU-specific procedures, with very few mortalities. When stratified using RODs into low-, intermediate-, and high-risk groups, significant differences were found with respect to age, nature of ICU admission, presence of chronic illness, utilization of ICU-specific procedures, having do-not-resuscitate (DNR) orders, length of ICU stay, and ICU and hospital outcomes.
Conclusions. Our study has provided crucial input for the study of strategic change towards more optimal utilization of scarce ICU resources. Implementing protocols to target ICU care to patients most likely to benefit, making DNR decisions early in the hospital stay, and operating an Intermediate Care Unit have been proposed as strategic approaches.
Keywords: do-not-resuscitate, intensive care, length of stay, resource utilization, risk of death
Address reprint requests to Yaseen Arabi MD FCCP, Deputy Chairman, Intensive Care Department (MC 1425), King Fahad National Guard Hospital, PO Box 22490, Riyadh 11426, Saudi Arabia. E-mail: arabi{at}ngha.med.sa
Accepted for publication November 24, 2003.
Patients with very short stay in intensive care units (ICUs) of <24 hours are often excluded from outcome studies, as the commonly used mortality prediction systems require 24 hours of data. They constitute a distinct group with special features: a high turnover rate and a unique patient mix. They include both low-risk patients, admitted to ICUs only for monitoring purposes, and high-risk patients, many of whom do not survive their ICU stay. The composition of this group varies between institutions, and is influenced by local resources and policies. It is important to study the features of this group of patients to have a better knowledge of their specific needs and requirements. Such an understanding could provide input for developing strategies towards improving local ICU admission practices and applying appropriate quality assurance tools.
Studies have shown that the use of objective predictions can help to accurately identify groups of ICU admissions at low risk for receiving life support, and thus assess ICU resource use and develop strategies for providing graded critical care services at a reduced cost [1]. The present study was therefore designed to examine the characteristics of patients admitted to ICUs for <24 hours, to categorize patients according to the nature of ICU admission and the estimated risk of death (ROD), and to correlate the utilization of ICU-specific procedures with ICU and hospital outcomes. It was expected that this research would result in some meaningful conclusions for effecting changes in hospital policies for better and more appropriate utilization of ICU resources and for optimizing patient care.
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Materials and methods |
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The study was conducted at the King Fahad National Guard Hospital, a 550-bed tertiary care teaching hospital in Riyadh, Saudi Arabia. Its adult medical/surgical ICU has 16 beds, with
600 admissions annually. The ICU is a closed unit, directed and staffed by full-time Board-certified intensivists, and has round-the-clock immediate access to other medical and surgical specialties. The nurse:patient ratio has been maintained at 1:1.2 because of the requirement for high acuity of care. A comprehensive database was established in March 1999 to record, prospectively, data related to all ICU admissions, their course and outcome. The hospital does not have an intermediate care unit (IMCU). There are separate coronary care and cardiac surgical intensive care units; the patients admitted in these units were not included in the study. Ethics committee approval was not required as the data had already been collected as a part of the database for clinical purposes. This study included all admissions in the ICU who stayed for <24 hours over a 24-month period, from March 1999 to February 2001. Readmissions within the same hospital stay and admissions for organ donations were excluded. Data on age, gender, nature of ICU admission, presence of chronic illnesses as defined by Knaus [2], ICU length of stay (LOS), ICU outcome and hospital outcome were collected prospectively as part of the ICU patient database. The main reasons for ICU admission were documented based on the list used in the article by Knaus [2] and were grouped into seven categories (see Appendix). It was also recorded whether the patients had do-not-resuscitate (DNR) orders.
Provision of the following ICU-specific procedures was documented: mechanical ventilation, bronchoscopy, non-invasive ventilation, pulmonary artery catheterization, intermittent hemodialysis or continuous venovenous hemodialysis (CVVHD), and intracranial pressure monitoring. Severity of illness was measured using the ROD of Mortality Probability Model II0 (MPM II0) [3], which estimates the probability of hospital mortality when the patient is admitted to the ICU. This model was chosen because it is based on data collected from the first hour after admission, while other severity-of-illness systems require 24 hours of data collection. The model incorporates data on physiological abnormalities (coma, tachycardia, and hypotension), chronic diagnoses (chronic renal failure, cirrhosis, and metastatic cancer), acute diagnoses (acute renal failure, arrhythmia, stroke, gastrointestinal bleeding, and intracranial mass effect), and other variables (cardiopulmonary resuscitation, mechanical ventilation, and whether admission was medical or following unscheduled surgery). The definitions of these variables and the logistic regression formula were used as described in [3].
Patients in the study group were categorized into two groups according to the nature of their ICU admission. Elective admissions included patients who had surgeries that were scheduled with at least 24 hours notice; other cases of unscheduled surgeries and all medical admissions were considered emergency admissions. The two groups were evaluated for differences in age and gender composition, presence of any chronic illness, ROD, DNR orders, provision of ICU-specific procedures, ICU LOS, and ICU and hospital outcomes.
Patients were also stratified into groups on the basis of ROD quartiles. The quartiles divide the patients into equal groups. Those within the quartiles on either side of the median (i.e. those between the first and third quartiles, Q1 and Q3) were combined as it was expected that they would not have very different features. Thus, there were three groups: group I, consisting of patients with lowest severity of illness (ROD <Q1); group II, consisting of patients with intermediate severity of illness (ROD 
Q1 and <Q3); and group III, comprising patients with high severity of illness (ROD Q3). This was considered a rational and objective approach for studying the patients. The characteristics and outcome of patients in these three groups were then compared.
The data collected were analyzed using the MinitabTM statistical software release-12 (Minitab, Inc.). Continuous variables were expressed as mean ± standard deviation, while categorical variables were expressed in absolute and relative frequencies. The chi-square test was used for analyzing categorical variables, and the t-test and analysis of variance (ANOVA) was used for continuous variables. P 
0.05 was considered statistically significant.
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Results |
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During the 24-month study period, there were 1095 admissions in the ICU; of these, 304 (27.8%) patients who stayed <24 hours constituted the study group.
Overall profile of the study group
Table 1 describes the overall profile of the study group. The following points deserve emphasizing. More than two-thirds of very short ICU stay admissions were emergency admissions. The most common reasons for admission to the ICU in this group were related to cardiovascular indications. Sixty-one (20.1%) patients had at least one chronic illness. Chronic liver disease was the most prevalent chronic illness, followed by chronic immunosuppressive diseases. The mean ROD was 30.7 ± 35.9%, and the estimated RODs ranged in value from 0.1% to 99.5%. Fifty-seven (18.8%) patients had written DNR orders after admission to the ICU. One or more ICU-specific procedures were performed for 138 (45.4%) patients. Mechanical ventilation (43.1%) was the most common procedure performed. Eighty patients died while in the ICU, giving an ICU mortality of 26.3%. Another 16 patients died in hospital after discharge from the ICU, giving a total hospital mortality rate of 31.6% in the study group.
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Categorization by nature of ICU admission
For the purpose of analysis, we grouped the patients admitted to the ICU by categories according to the nature of the admission, that is whether the admission was emergent or elective (Table 2). Emergency ICU admissions had a significantly higher mean age compared with elective admissions. Emergency admissions also included a significantly higher proportion of patients with one or more chronic illness. In respect of the chronic diseases studied, the proportions of patients with liver and renal diseases were higher among emergency admissions. The main reason for ICU admission in the elective group was postoperative indications, while cardiovascular-related indications were the leading cause of ICU admission in the emergency group.
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DNR orders were given for 26.3% of emergency admissions; this differed significantly from a mere 3% of elective admissions who had such orders. A majority (55.6%) of emergency admissions had one or more ICU-specific procedures performed, while less than a quarter (24.2%) of elective admissions had one or more of these procedures. Mechanical ventilation was provided for a significantly higher proportion of emergency admissions (53.7% versus 21.2%).
Emergency admissions were in the ICU for a significantly shorter duration (mean LOS 14.4 ± 6.6 hours) than elective admissions (18.9 ± 3.9 hours), and the ICU and hospital mortality rates were higher among emergency admissions (38.1% and 43.9%, respectively) than among elective admissions (2% and 6.1%, respectively).
Stratification using ROD
Study patients were stratified into three groups according to the ROD calculated by the MPM II0 model. The first and third quartiles (Q1 and Q3) were identified, and were 3.2% and 63.5%, respectively. The inter-quartile range of ROD (Q3 – Q1) was 60.3%. When the patients were stratified into groups using Q1 and Q3, groups I and III comprised one-quarter of the patients each, while group II comprised half the study group (Table 3).
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Patients in group III were older than those in groups I and II. While only 15.8% of patients in group I were emergency admissions, the corresponding proportion was found to be much higher in groups II (77.6%) and III (98.7%). In fact, group III had only a single case of elective admission. Patients in group III were in the ICU for a significantly shorter duration than those in groups I or II. The main reasons for ICU admission were significantly different among the three groups. Postoperative non-trauma reasons were the most common indication for ICU admission in groups I and II, while cardiovascular indications were the most common indication in group III.
Only 4% of patients in group I had any chronic illness, compared with 46.1% in group III. While there was not much difference within group II with respect to the prevalence of each of the five chronic diseases categories, in group III chronic liver disease predominated (29%), followed by chronic immunosuppressive diseases (13.2%).
A significantly higher proportion of group III patients had DNR orders as compared with those in groups I and II. On analysis of ICU-specific procedures performed, significant differences were found among the groups only with respect to mechanical ventilation and pulmonary artery catheterization. Only one (1.3%) patient in group I died while in the ICU, in sharp contrast to 71 (93.4%) in group III.
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Discussion |
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ICUs consume an intense proportion of the hospital resources [4,5]. The greatest challenge in provision of ICU care is deciding who would and would not benefit from ICU and, thus, who should ideally be cared for in these resource-intense facilities [6]. Using inputs from systematic studies for planning, we can enhance the provision of quality care for more patients and ensure more optimal utilization of resources through better-targeted and more efficient services.
Our study of patients with ICU stay of <24 hours demonstrated that they form a heterogeneous group. Upon categorizing them as elective or emergency admissions, striking differences in characteristics were seen between the groups, with elective admissions comprising younger patients with a significantly lower prevalence of chronic illness, lower ROD, and utilization of fewer ICU-specific procedures, and with very few DNR orders and mortalities. Therefore, this group should be targeted differently from that of emergency admissions while refining ICU admission policies.
By stratifying patients based on ROD, we were able to distinguish high- and low-risk groups widely differing in their characteristics (age, nature of ICU admission, presence of chronic illness, ICU-specific procedure performed, having DNR orders), LOS, and ICU and hospital outcomes. This bears out the adopted approach of using ROD quartiles Q1 and Q3 to stratify patients into groups. The wide inter-quartile range shows that the middle half of the various ROD estimates has a spread covering nearly three-fifths of the ROD values.
Our study showed that one-quarter of patients staying in the ICU for <24 hours had a low probability of death, with an ROD of 3.2%. However, these patients, 84.2% of whom were elective admissions, had a significantly longer ICU stay (18.1 ± 4.5 hours) than others. Among them, only 4% had any chronic illness, 2.6% had DNR orders, and 14.5% had any ICU-specific procedure performed on them; only one patient died while in the ICU. Thus, we have a clearly identified group that rarely requires or receives ICU-specific interventions. Most low-risk ICU monitor admissions, especially postoperative cases, could safely be cared for in an extended recovery area or an IMCU [1,7]. This would result in considerable saving of resources, with 1 day of hospitalization in an IMCU costing only one-third of that in an ICU [8]. More importantly, from the patient care point-of-view, it would free up ICU beds and resources for more critical cases in need of high acuity intensive care.
We were also able to identify a group of patients with a very high risk of death (ROD Q3). Among them, 98.7% were emergency admissions, 46.1% had one or more chronic illness, 90.8% required one or more ICU-specific procedures, and 59.2% had DNR orders. The high ICU mortality rate of 93.4% in this group may account for the short ICU LOS of 10.2 ± 6.8 hours. While most of these ICU admissions are justified, one has to question whether some ICU admissions were for patients who had no meaningful hope of recovery, especially those who had written DNR orders within a few hours of ICU admission. Identifying patients who are unlikely to benefit from ICU care before ICU admission could have avoided some of these futile admissions.
It is well accepted that early appropriate referral of patients to an ICU can significantly reduce early, and possibly late, mortality in the critically ill [9,10]. At the same time, improper selection of patients for ICUs who block ICU beds often limits bed availability in ICUs. This, in turn, adversely affects the dynamics of the whole hospital. It causes cancellation of scheduled elective surgeries with attendant consequences, such as higher idle operating room time, underutilization of the surgeons, anesthetists, and nursing and other personnel, and prolongation of waiting lists on the surgical floor. Necessary surgeries being delayed may adversely affect the patients’ health, besides exposing them to the risk of hospital-acquired infections due to their prolonged hospital stay. This suboptimal utilization of beds is an avoidable drain on the hospital’s resources.
Zimmerman et al. [8] have suggested, based on their study of 40 US hospitals, that if ICU low-risk monitor patients were admitted to an IMCU, they would mainly require concentrated nursing care with a nurse:patient ratio of 1:3 to 1:4, and limited technologic monitoring. Another study of patients receiving neurological care at ICUs concluded that those who receive only monitoring during their first ICU day and have a <10% predicted risk of active treatment, can safely be transferred to an IMCU [11]. Implementing protocols to target ICU care to patients most likely to benefit may decrease the number of low-severity ICU admissions and improve the cost-effectiveness of ICU care [3].
The timing of writing DNR orders has been associated with shortening needed hospital and ICU care, as well as effecting significant reductions in resources utilized. The use of DNR orders, particularly early in the ICU stay, may be associated with significant reduction in resource use for an identifiable group of patients [12]. In their study of DNR order use for ICU patients in four US teaching hospitals, Rapoport et al. reported that such use, particularly early in ICU stay, was associated with significant resource use reduction [13].
The DNR decision was not commonly practiced in our hospital till 1998, when a new DNR policy developed by a task force was approved and implemented. This was based on Fatwa No. 12086 issued by the Residency of the Administration of Islamic Research and Ifta at Riyadh on 6 February 1989, which clarified the Islamic religion’s concepts concerning the DNR decision. The decision on DNR is made by the ‘most responsible physician’, and requires review and endorsement by another consultant and a third physician. After the decision has been explained and accepted by the patient or the most appropriate family member, the patient’s chart is flagged with the DNR sign.
Implementing the policy had resulted in substantial increase of DNR orders for terminal patients. However, a number of these patients who are unlikely to benefit from ICU are still admitted to the ICU and their code status is only determined thereafter. Had their code status been determined earlier in their hospital stay, it can safely be conjectured that they could have been cared for in the ward without being moved to the ICU. It has been estimated that a day’s hospitalization in the ward costs only one-sixth of that in the ICU [8]. By making a decision on DNR early in the hospital stay, we can continue to treat the DNR patients in the ward and need not admit them to the ICU.
The strengths of our study include the prospective data collection and the use of a severity of illness measure. The limitations of the study include being a single-center study and being based on data obtained after ICU admission. An alternative design of such a study would be to include all potential ICU candidates. Such a study would have been more difficult to conduct and would be more subject to variation in referral practices to the ICU service. In contrast to our design where data were collected at a fixed point (the first hour of ICU admission), in the later design data will be collected at a greatly variable time related to ICU admission, adding another confounding factor. Finally, the patients’ outcome in the later design would be profoundly affected by the availability of ICU beds, which is not an issue in our current design, as the patients have already been admitted to the ICU.
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Our study has provided an objective way of assessing high- and low-risk admissions with respect to very short ICU stay. Adopting such an approach will enable hospitals to draw up strategic plans for targeting these patients in their ICU admission policies; this could substantially improve the dynamics of both the ICU and the hospital. Making DNR decisions early in the hospital stay and operating an IMCU are possible strategic approaches for optimizing the use of ICU resources. Implementing these meaningful measures will release more ICU beds, enabling more elective surgeries to be performed, thus ensuring better utilization of the operating room and the medical and nursing manpower, and shortening the waiting time for elective surgeries.
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Appendix |
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Reasons for ICU admission
Respiratory. Asthma/allergy, chronic obstruction pulmonary disease (COPD) exacerbation, pulmonary edema (ARDS), respiratory arrest, aspiration/poisoning/toxic, respiratory infection, pulmonary embolus, pulmonary neoplasm.
Cardiovascular. Hypertension, rhythm disturbance, congestive heart failure, hemorrhage/hypovolaemic shock, coronary artery disease, sepsis, postcardiac arrest, dissecting thoracic/abdominal aneurysm, cardiogenic shock.
Neurologic. Seizure disorders, intracranial/subdural/subarchanoid hemorrhage.
Other non-operative. Drug overdose, diabetic ketoacidosis, gastrointestinal bleed, other metabolic/renal, other respiratory, other neurological, other cardiovascular, other gastrointestinal.
Non-operative trauma. Multiple trauma, head trauma.
Operative trauma. Postoperative multiple trauma, postoperative head trauma.
Postoperative. Postoperative chronic cardiovascular disease, postoperative peripheral vascular surgery, postoperative heart valve surgery, postoperative craniotomy for neoplasm, postoperative renal surgery for neoplasm, postoperative renal transplant, postoperative thoracotomy for neoplasm, postoperative craniotomy for intracranial/subdural/subarchanoid hemorrhage, postoperative laminectomy and spinal cord surgery, postoperative with haemorrhagic shock, postoperative gastrointestinal bleed, postoperative GI neoplasm, postoperative respiratory insufficiency, postoperative GI obstruction/perforation, postoperative other neurological, postoperative other cardiovascular, postoperative other respiratory, postoperative other gastrointestinal, postoperative other metabolic/renal.
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