Closure of an Intermediate Care Unit: Discussion

When hospital structure and organization change, the utilization of key service components, such as critical care, also changes. The high costs of critical care and the limited access to these services necessitates an organized approach to resource management during periods of adjustment. Reports of CCU utilization often study altered patterns of use when a “step-down unit” or ICA is opened. Our data demonstrated the extent of altered utilization of a multidisciplinary CCU when an ICA was closed and emphasized the need for a utilization management system. The two key changes in utilization pattern were the increased number of patients admitted with a low severity of illness and an increased number of patients discharged with significantly lower nursing workload requirements. The magnitude of these two changes in utilization pattern was large (Table 2), yet commonly used measures, such as length of stay, did not detect them. If physicians are to participate effectively in resource management with nursing and administrative colleagues, we must develop an organized approach to utilization analysis to understand the factors that influence and measure use of resources. canadian family pharmacy online

This study demonstrates the value of the APACHE II methodology as a validated tool for utilization assessment and emphasizes the need to develop more validated measures of nursing workload. Our experience also suggests that the beneficial effects reported with creation of an ICA are reversed if the unit is closed and reinforces the concept that the presence of an ICA altered decision-making in a CCU. The strategy of identifying “low-risk” groups requiring fewer nursing resources and allocating these patients to less intensively monitored or staffed locations was inhibited by closing the ICA.
Critical care physicians and nurses have two potential options to manage access to critical care facilities. The first strategy is to establish independent ICAs that provide limited, well-defined intermediate levels of care to decrease demand for critical care beds. The alternate strategy would be the development of flexible staffing patterns and resource use within a multidisciplinary CCU. For efficient use of personnel and resources, this option would necessitate stratification of critical care delivery according to patient need within a diverse unit. Altering the supply of and demand for critical care resources could theoretically be accomplished by either strategy, and either appears preferable to formal explicit rationing.
Cost considerations and increased throughput have been the prime impetus encouraging alternate sites of care for critically ill patients. Spivack has estimated that approximately $106,000 could be saved annually per hospital if 10 percent of patients were diverted from a 15-bed CCU with a 95 percent occupancy rate to a noninvasive unit. He estimated that implementing this strategy nationally in the United States could result in a $500 million saving. We found that dismantling the ICA resulted in 136 CCU patient admissions with APACHE II scores less than 15 as compared with 30 in the pre-ICA closure period. This increase represented approximately 25 percent of total CCU admissions, but accounted for less than 10 percent of CCU bed days in the 9 months after ICA closure.

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