Rationing critical care beds: A systematic review*

Objective:Rationing critical care beds occurs daily in the hospital setting. The objective of this systematic review was to examine the impact of rationing intensive care unit beds on the process and outcomes of care. Data Source:We searched MEDLINE (1966–2003), CINAHL (1982–2003), Ovid Healthstar (1975–2003), EMBASE (1980–2003), Scisearch (1980–2003), the Cochrane Library, PUBMED related articles, personal files, abstract proceedings, and reference lists. Study Selection:We included studies of seriously ill patients considered for admission to an intensive care unit bed during periods of reduced availability. We had no restriction on study design. Studies were excluded if rationing was performed using a scoring system or protocol and if cost-effectiveness was the only outcome. Data Extraction:In duplicate and independently, we performed data abstraction and quality assessment. Data Synthesis:We included ten observational studies. Hospital mortality rate was increased in patients refused intensive care unit admission vs. those admitted (odds ratio, 3.04; 95% confidence interval, 1.49–6.17). Factors associated with both intensive care unit bed refusal and increased mortality rate were increased age, severity of illness, and medical diagnosis. When intensive care unit beds were reduced, admitted patients were sicker, were less often admitted primarily for monitoring, and had a shorter intensive care unit length of stay, without other observed adverse effects. Conclusions:These studies suggest that patients who are perceived not to benefit from critical care are more often refused intensive care unit admission; refusal is associated with an increased risk of hospital death. During times of decreased critical bed availability, several factors, including age, illness severity, and medical diagnosis, are used to triage patients, although their relative importance is uncertain. Critical care bed rationing requires further investigation.

[1]  J. E. Carceller Consensus Statement of the Society of Critical Care Medicine , 1984, Critical care medicine.

[2]  C. Durbin,et al.  Influence of political power, medical provincialism, and economic incentives on the rationing of surgical intensive care unit beds , 1992, Critical care medicine.

[3]  S. Keenan,et al.  A systematic review of the cost-effectiveness of noncardiac transitional care units. , 1998, Chest.

[4]  Klim McPherson,et al.  Mortality among appropriately referred patients refused admission to intensive-care units , 1997, The Lancet.

[5]  T. Evans,et al.  Allocation of resources in intensive care: a transatlantic perspective , 1994, The Lancet.

[6]  Utilization strategies for intensive care units. , 1989, JAMA.

[7]  G. Fetherston,et al.  The medical emergency team , 2001, The Medical journal of Australia.

[8]  Attitudes of critical care medicine professionals concerning distribution of intensive care resources , 1994, Critical care medicine.

[9]  C. Sprung,et al.  Evaluation of triage decisions for intensive care admission. , 1999, Critical care medicine.

[10]  Michael J. Strauss,et al.  Rationing of intensive care unit services. An everyday occurrence. , 1986, JAMA.

[11]  Douglas K. Martin,et al.  Seasonal bed closures in an intensive care unit: a qualitative study. , 2003, Journal of critical care.

[12]  Tien Chey,et al.  Rates of in‐hospital arrests, deaths and intensive care admissions: the effect of a medical emergency team , 2000, The Medical journal of Australia.

[13]  J. Vincent,et al.  Guidelines for the utilisation of intensive care units , 2005, Intensive Care Medicine.

[14]  N. Laird,et al.  Meta-analysis in clinical trials. , 1986, Controlled clinical trials.

[15]  Robert M. Nelson,et al.  Consensus Statement on the Triage of Critically III Patients , 1994 .

[16]  G. Smith,et al.  Meta-analysis Spurious precision? Meta-analysis of observational studies , 1998, BMJ.

[17]  M. Egger,et al.  Meta-analyses of observational data should be done with due care , 1999, BMJ.

[18]  C. Goldfrad,et al.  Consequences of discharges from intensive care at night , 2000, The Lancet.

[19]  M. Osborne,et al.  Ethical allocation of ICU resources: A view from the USA , 1996, Intensive Care Medicine.

[20]  黄亚明,et al.  European Society of Intensive Care Medicine , 2005, Intensive Care Medicine.

[21]  D. Singer,et al.  Rationing intensive care--physician responses to a resource shortage. , 1983, The New England journal of medicine.

[22]  Gavin Joynt,et al.  Prospective evaluation of patients refused admission to an intensive care unit: triage, futility and outcome , 2001, Intensive Care Medicine.

[23]  J C Bailar,et al.  The practice of meta-analysis. , 1995, Journal of clinical epidemiology.

[24]  D. Cook,et al.  Does quality of reports of randomised trials affect estimates of intervention efficacy reported in meta-analyses? , 1998, The Lancet.

[25]  Sylvie Chevret,et al.  Compliance with triage to intensive care recommendations , 2001, Critical care medicine.

[26]  David J. Dries,et al.  GATEKEEPING IN THE INTENSIVE CARE UNIT , 1998 .

[27]  P. Ubel,et al.  Recognizing Bedside Rationing: Clear Cases and Tough Calls , 1997, Annals of Internal Medicine.

[28]  R. C. Dennis,et al.  Guidelines on admission and discharge for adult intermediate care units. American College of Critical Care Medicine of the Society of Critical Care Medicine. , 1998, Critical care medicine.

[29]  George Davey Smith,et al.  Meta-analysis: Principles and procedures , 1997, BMJ.

[30]  J. Shelhamer,et al.  Fair Allocation of Intensive Care Unit Resources , 1997 .

[31]  I. Olkin,et al.  Improving the quality of reports of meta-analyses of randomised controlled trials: the QUOROM statement , 1999, The Lancet.

[32]  I. Olkin,et al.  Improving the quality of reports of meta‐analyses of randomised controlled trials: the QUOROM statement , 2000, Revista espanola de salud publica.

[33]  J. Fleiss,et al.  The statistical basis of meta-analysis. , 1993, Statistical methods in medical research.

[34]  V. Beral "The practice of meta-analysis": discussion. Meta-analysis of observational studies: a case study of work in progress. , 1995, Journal of clinical epidemiology.

[35]  R. Byrick,et al.  Structural models for intermediate care areas. , 1999, Critical care medicine.

[36]  Martin A. Strosberg,et al.  Gatekeeping in the Intensive Care Unit , 1997 .

[37]  R. Byrick,et al.  Closure of an intermediate care unit. Impact on critical care utilization. , 1993, Chest.

[38]  S. Walther,et al.  A prospective cohort study of 6-month mortality in a community hospital experiencing a gradual reduction in critical care services , 2001, Intensive Care Medicine.

[39]  A. Porath,et al.  Rationing critical care -- what happens to patients who are not admitted? , 1994, Theoretical surgery.

[40]  I. Olkin,et al.  Meta-analysis of observational studies in epidemiology - A proposal for reporting , 2000 .