A combination of physician and institutional factors impact decisions on placing patients into intensive care units.
Hospitals and health systems can reduce costs and produce improved patient outcomes by assigning patients to intensive care unit (ICU) treatment appropriately. There are two patient groups that go into the ICU when they may not necessarily benefit from that care, say researchers: those who are not sick enough to benefit from intensive care and those who are so sick that no matter what medical care is applied, they won’t have good outcomes.
Determining Reasons for Inappropriate ICU Use
First, physicians want to provide the best care they can, but they can mistake intensive care for better care, according to a study published in JAMA Internal Medicine, titled “Association Between Intensive Care Unit Utilization During Hospitalization and Costs, Use of Invasive Procedures, and Mortality.”
“Intuitively, as physicians, we think that if we have better monitoring and higher levels of care in an ICU, patients will do better there. But we don’t necessarily understand that if we have this tendency to put patients in high-level settings, we often provide care that’s a bit more invasive than we actually want,” says Dong W. Chang, MD, MS, a physician in the Division of Respiratory and Critical Care Physiology and Medicine at Harbor-UCLA Medical Center and an assistant professor of medicine at the David Geffen School of Medicine at UCLA. Chang authored the study with Martin F. Shapiro, MD, PhD, Division of General Medicine and Health Services Research, David Geffen School of Medicine at UCLA.
The researchers found no improvement in mortality for patients treated in the ICU, but they do receive more invasive and costly care.
The second category of patients who may not benefit from ICU care are those who are too sick to benefit from intensive care. “Physicians are not willing to give up on those patients. We want to give them the benefit of the doubt. We want to give maximum medical care and see if they recover,” says Chang.
“There is an under-recognition that more invasive care can place certain patients at risk for more harm down the line, and certain patients wouldn’t derive a lot of benefit from intensive care because their prognosis is poor,” says Chang.
Finally, systematic factors can also affect ICU use. Because there are protocols that can only be delivered in the ICU, certain patients must be treated there even if equivalent clinical care could be delivered in non-ICU settings.
Identifying Common Conditions For Overtreatment
Patients with certain conditions are more likely to be overtreated in the ICU. For example, Chang notes that many patients with diabetic ketoacidosis (the body contains too much acid) may be brought into the ICU because certain protocols related to treating that condition only can be handled in the ICU. However, beyond those protocols these patients may not exhibit any other signs that they need ICU care.
Other examples include patients with mild upper gastrointestinal infections or congestive heart failure. With initial care outside the ICU, these conditions may improve, but physicians often are overly cautious and bring patients into the ICU anyway.
On the other side of the spectrum are patients who are extremely ill and have less likelihood to benefit from ICU care because of high levels of comorbid conditions that are either terminal, intractable, or progressive, such as advanced cancer or advanced dementia.
“For example, patients with poor baseline functional status and quality of life from end-stage cancer or dementia have progressive, intractable medical conditions, but many patients with these illnesses are still receiving aggressive ICU care even though they are unlikely to benefit from it,” says Chang.
Taking Steps to Stem ICU Overuse
Hospitals can take certain steps to place patients in cost-effective care settings that offer positive outcomes. “The first step is to recognize that this is not just an ICU problem. The best time to address appropriate care is in the outpatient setting when patients and their families can think through their goals and preferences for care,” says Chang.
Patient and family communication. Conversations about the aggressiveness of care, patient preferences and values, and placing certain limits on treatment that won’t be beneficial should occur before patients find themselves in the hospital.
The critical nature of ICU care poses challenges. ICU physicians make rapid decisions about sick patients, so they are in a compromised position to speak with patients and their families. In addition, sometimes patients are too sick to make serious decisions, and their families are also under stress.
“Trying to make difficult decisions in a time-compressed, stressed manner is extremely challenging. But that’s not to say that we can’t do things, even within our ICU, to ensure proper utilization of treatment options,” says Chang.
In addition, there is often misunderstanding and miscommunication between patients and their family members about the benefits and risks of an ICU setting.
“There’s misperception that when patients come into the ICU they will receive certain care and they are going to get better, when in reality, that’s not the case. We are working on ways to improve that communication between physicians, patients, and family members, so that we get at the most likely scenarios and make the best decisions,” says Chang.
Ways to improve communication include offering provider training, using protocols during family meetings to ensure important topics are addressed, and ensuring that meetings occur early during the ICU course of treatment with frequent follow-up.
Patient preferences. The next step is understanding patients’ preferences and values and determining whether the care that is provided in the ICU realistically aligns with what they would prefer.
To that end, electronic health records have helped improve information sharing across hospitals, says Chang. “Electronic health records are certainly an important step, but they are imperfect. It is very helpful when we have access to documentation regarding previous discussions on patient preferences for care. We’re often dealing with rapid situations, during which patients may need invasive interventions rapidly, so we frequently do not have time to have detailed discussions about their preferences or an evaluation of the appropriateness of that aggressive care,” says Chang. “A more reliable system would ensure that everyone has discussed and placed into their medical records their wishes and preferences.”
Outpatient practices. Starting conversations about the use of intensive care when patients are still receiving outpatient care is helpful in setting expectations as conditions worsen. “We need to discuss all the things that ensure that patients receive the level of care that aligns with their goals and values before they get to the hospital and potentially come into the ICU,” says Chang.
Choosing Appropriate Care Settings
For patients who are extremely ill and unlikely to benefit from ICU treatment, options include hospice care or long-term care facilities. “Often, my preference is to recognize that ICU care in patients with advanced medical illnesses frequently will lead to health states that prolong suffering. In such cases, we should recognize that palliative care is what’s best,” says Chang.
“There are multiple studies that have surveyed patients with advanced medical conditions about their care preferences. Almost uniformly, those studies suggest that patients prefer palliative care over advanced critical care,” says Chang.
For patients who are not sick enough to be treated in the ICU, lower-acuity levels of care, such as progressive care units (PCUs)—where patients receive close monitoring and extra nursing care, but not at the same intensity level as in an ICU—or ward beds with telemetry and other monitoring equipment will likely be better for those patients, says Chang.
Widespread Problem
Chang notes that other researchers have found similar large percentages of hospital patients receiving critical care when they didn’t have the prognosis with acuity to benefit from it.
“The magnitude of the problem has helped me understand how important it is to address it nationally. It is important to start a discussion about improvements, especially among patients who are too sick for ICU treatment. I think we’re potentially doing harm by providing invasive care instead of focusing on things like palliation,” says Chang.
Identifying alternative protocols and establishing lines of communication between patients, families, and caregivers can go a long way toward improving patient outcomes and experience while reducing unnecessary use of costly ICU treatment.
Interviewed for this article:
Dong W. Chang, MD, MS, is a physician in the Division of Respiratory and Critical Care Physiology and Medicine, Harbor-UCLA Medical Center and an assistant professor of medicine, David Geffen School of Medicine at UCLA.
