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Making ICU Admissions Smarter, Not Making Them Harder: Lowering ICU Admission Thresholds Improves Outcomes and Resource Utilization FREE TO VIEW

Joseph Carrington; Jaime Barnes
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Northwest Hospital, Lifebridge Critical Care, Randallstown, MD

Chest. 2015;148(4_MeetingAbstracts):246A. doi:10.1378/chest.2270816
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SESSION TITLE: Critical Care Posters III

SESSION TYPE: Original Investigation Poster

PRESENTED ON: Wednesday, October 28, 2015 at 01:30 PM - 02:30 PM

PURPOSE: Medical resources are limited and intensive care is expensive. This creates a culture of higher thresholds for ICU admissions and increased utilization of intermediate care units (IMC). Early triage to appropriate levels of care may improve mortality, shorten ICU length of stay (LOS), and decrease cost.

METHODS: This is a retrospective study of 886 charts from a 16-bed closed ICU in a community hospital comparing mortality and LOS before and after a culture change of lowering ICU admission thresholds. There was collaboration between the emergency department (ED) and ICU in admitting traditionally “borderline” patients to the ICU, as well as utilizing standardized ICU admission criteria for septic patients. Severity of illness was compared using case-mix index (CMI) values.

RESULTS: Crude mortality decreased by 45.4%, from 14.38% to 7.85% post-implementation (p = 0.03) (mean difference 6.53%, 95% CI of 0% to 13%), even though severity of illness did not change (mean difference of 0.01, with 95% CI of -0.03 to 0.02). ICU LOS was also 25.9% lower in the post-implementation cohort (3.97 days versus 2.94 days, p=0.009) (mean difference 1.03 days, 95% CI of 0.00 to 2.05). The percent of IMC to ICU transfers decreased by 67.1%, from 3.89% to 1.28%.

CONCLUSIONS: After developing a collaborative culture between the ED and ICU with lower ICU admission thresholds and standardized ICU admission criteria for patients with sepsis, we demonstrated a significant decrease in crude mortality, ICU LOS, and IMC to ICU transfers. In addition to improved outcomes, annualized cost savings in our new model were $2,286,600 (based on average cost of $2500.00/ICU-day).

CLINICAL IMPLICATIONS: Although ICU level of care is costly, earlier inclusion of borderline patients may improve mortality and overall significantly decrease resource utilization. These data indicate that there may be a benefit in smarter use of ICUs, rather than making ICU admissions harder.

DISCLOSURE: The following authors have nothing to disclose: Joseph Carrington, Jaime Barnes

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