People Die When ICUs Deny Admissions

Spoon Feed
Lack of a MICU bed doesn’t mean the ED patient is not critically ill.  The longer patients whom the ED determined needed ICU care boarded in the ED before being moved to the ICU, the greater the odds of mortality.

Why does this matter?
ED boarding with admitted patients is getting worse.  Boarding an ICU patient in the ED can quickly overwhelm our resources.  When the ICU is full, the ED becomes the ICU.  Prior studies have shown that denial of ICU admits from the ED increases mortality.  So you won’t be surprised to find out what this study showed.

Intensive care is about resources not location
This was a clever retrospective study and propensity analysis of patients at a single center in NY that compared patients who needed ICU-level care who were blocked from getting an ICU bed and those who were accepted.  They found that only 53% of ED requests for a MICU bed were accepted.  First of all, this level of obstruction must be maddening to these ED docs.  Next, the only hospital-level factor associated with denial of ICU admission was a full ICU.  Lack of a MICU bed doesn’t mean the ED patient is not critically ill.  It just means the ICU raises the bar, and the ICU patient languishes in the ED or gets inappropriately sent to the floor.  We have a unique skill set in the ED.  All day we make disposition decisions on every patient we see: home, admit, ICU, step-down, ward, etc.  No one in the hospital does this more than we do. Bad things happen when we determine a patient needs ICU care, but the ICU refuses.  Boarding was associated with mortality.  See figure.

The ED decision doesn’t hinge on ICU bed space; it hinges on the patient’s status.  It doesn’t mean we can’t initiate ICU level care.  It does seem to mean we can’t sustain it.  This MICU had mandatory 2:1 patient/nurse ratios; the ED had 3:1 or more.  And the ED can’t limit influx of new patients like the ICU can.  They just keep coming, often when we are already “full.”  One answer is that when the ED says they need an ICU, the ICU makes room by overflowing patients into other open, non-MICU, critical care beds.

Source
Effect of Emergency Department and ICU Occupancy on Admission Decisions and Outcomes for Critically Ill Patients.  Crit Care Med. 2018 Jan 30. doi: 10.1097/CCM.0000000000002993. [Epub ahead of print]