Who goes to the ICU and why?

More is not always better when it comes to hospital care. The same interventions that could save one patient’s life could lead to no benefit, higher hospital bills and even injury for another.

A University of Michigan led study published in the journal Intensive Care Medicine interviewed almost 90 clinicians and hospital staff and performed onsite observations across eight unaffiliated hospitals in Michigan to understand why different hospitals used the intensive care unit more than others.

“You would think it should be obvious which patients need ICU care—the ‘sickest’ patients. But we found that whether a patient needs ICU care really depends on which hospital they’re at,” said Thomas Valley, M.D., assistant professor in the Division of Pulmonary and Critical Care Medicine and lead author to the study. “Some hospitals had no problems caring for complex patients in non-ICU areas, like general wards. These patients weren’t felt to get much additional benefit from being in an ICU. On the other hand, patients in hospitals without a lot of experience caring for sick patients spent a lot of time and resources focused on making sure these patients who were sick received ICU care.”

The authors found several factors that influenced whether a patient would receive ICU care. The first was availability of ICU beds, with critically ill patients often kept in the emergency department when ICU beds were full.

The second was staff characteristics, such as their comfort with taking care of sicker patients or whether an ICU nurse was available. In particular, the authors found that some ICUs frequently had to close off their ICU beds because they didn’t have sufficient ICU nurses to operate them.

The third factor was the hospital’s place within the existing networks of interhospital transfers. For example, smaller hospitals often expedited interhospital transfers in order to avoid delays that might pop up later during the hospitalization, such as if bad weather were to occur.

Finally, hospital policies related to ICU admission dictated some decisions to put patients in the ICU—with some care providers basing the decision on misunderstood or non-existent policies around who qualifies for care.

And while medical guidelines dictate that decisions around ICU admission be driven by how likely it is that a patient will benefit from ICU care, in everyday practice, trying to figure that out is almost impossible, state the investigators.

Instead, the authors believe that we may need to move away from universal guidelines so that individual hospitals can develop their own strategies to ensure their sickest patients always receive ICU care.

Additional authors: Amanda Schutz, Jacquelyn Miller, Lewis Miles, Kyra Lipman, Tammy L. Eaton, Colin R. Cooke, all with University of Michigan; Harish Kinni, Henry Ford Hospital; and Theodore J. Iwashyna, Johns Hopkins University

Paper cited: “Hospital factors that influence ICU admission decision‑making: a qualitative study of eight hospitals,” Intensive Care Medicine. DOI: 10.1007/s00134-023-07031-w