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High-dependency units: reducing the cost of intensive care without loss of quality

1998; Lippincott Williams & Wilkins; Volume: 15; Issue: 6 Linguagem: Inglês

10.1097/00003643-199811000-00024

1365-2346

T. Prien,

Sepsis Diagnosis and Treatment

Facing burgeoning costs, health care performance is increasingly scrutinized by health insurance providers and society. Evidence has mounted that there is waste and redundancy and that more efficient delivery of health care does not decrease quality. Even though the efforts to reduce waste and redundancy can be beneficial, cost-cutting measures may also result in reduced quality of care and worse patient outcomes. In particular, intensive care medicine may be sensitive to financial curtailment because it is expensive. However, the potential for quality neutral savings in intensive care medicine is presumably not very large: human resources (quantity and quality of the staff working in the intensive therapy unit, ITU) are by far the largest single item of expenditure [1] and the backbone of intensive care. Reducing the cost of intensive care medicine without loss of quality is tantamount to a rationalization process, i.e. achieving the same results at less cost. For this purpose, intensive care medicine needs to be assessed in terms of both its overall cost-effectiveness and the cost-effectiveness of its specific components [2]. However, to study single interventions is a difficult, if not insoluble, task in this heterogeneous patient group with multiple complex problems. This has to be kept in mind when randomized controlled trials are demanded by health care administrators as a prerequisite for expensive interventions in the critically ill. Regardless of whether specific components or the whole process of intensive care medicine is analysed, an exact description of inputs (e.g. diagnosis, severity of disease scores) and outputs/outcome (e.g. survival rates, quality-adjusted life years, SF-36) is required. Among others, organizational structures have been demonstrated to have considerable impact on outcome data [3]. In particular, overutilization of intensive care medicine has been claimed as an unnecessary source of costs. For example, a study supported by the Dutch ministry of health concluded that the majority of intensive care units in the Netherlands served important recovery room functions and recommended that recovery rooms in hospitals should operate on a 24-h basis, avoiding widespread inappropriate use of ITU facilities [4]. It is argued that high-dependency units (HDUs, synonymous with intermediate care units, intensive observation units, step down units) or recovery rooms (post-anaesthesia care units, PACUs) can undertake many of the traditional roles of the intensive therapy unit (ITU) at a fraction of the cost, because costs per patient day are considerably lower in the HDU (PACU) than in the ITU. Singer et al. [5] compared the costs in the ITU and adjacent HDU of a central London teaching hospital. In 1991, average costs per patient per day were £1148.72 in the ITU and £234.54 in the HDU. As these are average costs (including 'monitor' patients as well as patients with multiple organ failure), it cannot be inferred from these data that one day of a 'monitored' patient in the HDU is ≤£900 cheaper compared with the ITU. Rather, the 'monitor' patient will require the same monitors, the same medication, the same supplies, the same diagnostic tests and the same amount of nursing time; in other words, the variable costs for this patient will be roughly similar, regardless of where he is treated. There will only be a certain difference with regard to fixed costs (building depreciation, equipment depreciation, infrastructure maintenance, energy supply, cleaning, etc.), which are usually higher for the ITU. It is important to have intermediate care facilities like HDUs or PACUs, but only to meet the increasing demands for intermediate care, not in order to reduce costs. It is not the ITU that is expensive, but the therapy of the patients who are treated there. Treating these patients elsewhere will, at best, not result in major savings, provided that the quality of care (i.e. amount of human work, treatment modalities) is not to be sacrificed. It has to be recalled that the effective and economic utilization of human and technical resources was one of the rationales for the creation of ITUs (i.e. concentration of the seriously ill in a certain area of the hospital). If these patients were not concentrated but rather treated separately on the wards, similar treatment there would be far more expensive than in the ITU environment. Nevertheless, the functional and organizational subdivision of intensive care into ITUs and HDUs is a useful concept, provided that the hospital's size is large enough and that the number of intensive care beds required exceeds that of the ideal ITU upper size of 8-10 beds [6,7]. In West Germany, this concept has been promoted by the German Hospital Society (Deutsche Krankenhaus Gesellschaft; DKG), an organization of hospital owners, as early as 1974 when guidelines for the organization of intensive care medicine were published [8], which say inter alia: 'The organisation of intensive care medicine depends on the size and structure of the respective hospital. For medical, organizational, and economic reasons, a centralization of intensive care medicine within one area should be sufficient. In university hospitals as well as in hospitals of comparable size (more than 800 beds), the following units should be provided: Observation units (or areas) within the medical departments. For intensive therapy, integrated, interdisciplinary units of two types: one for the operative departments and one for the medical departments. In addition, special department-linked ICUs may be necessary (e.g. cardiology, haemodialysis, detoxification, neurology, paediatrics). In hospitals of intermediate size (300-900 beds), the following integrated units should be provided: One ICU for the operative departments. One ICU for the medical departments.These units should enclose intensive observation beds and intensive therapy beds within the same area.Again, special department-linked ICUs may be necessary. In small hospitals (up to 300 beds), intensive observation and intensive therapy are to be consolidated in one central unit. Very small hospitals, which cannot provide such a unit, must be prepared for basic intensive therapy measures when they prove to be necessary.' HDUs have lower indirect costs compared with ITUs, which have to meet different and more expensive requirements for floor plan, energy supply, climatization, major equipment, etc. For example, the German Interdisciplinary Society for Intensive Care and Emergency Medicine (DIVI; Deutsche Interdisziplinäre Vereinigung für Intensiv- und Notfallmedizin) recommends the 'open' patient area as acceptable for HDUs, whereas ITUs should be structured into one or two bed rooms [9]. With regard to the high and increasing number of patients requiring intensive care following elective surgery for approximately 24 h, at least in larger hospitals, another subdivision of intensive care into short-term and long-term units may prove to be useful and effective. The concept of a separate short-term ITU includes: location adjacent to the operating rooms; 'open' plan (as opposed to one- or two-bed rooms); higher flexibility of the nursing staff; transfer of the patients on the morning of the next working day (to long-term ITU, HDU or ward) in order to be ready to accept new patients. Such a concept can be realized by operating the PACU on a 24 h basis [10]. Historically, recovery rooms were established in order to reduce complications in the period immediately after surgery and anaesthesia, using staffing and equipment resources economically. To minimize the incidence of postoperative complications remains the main task of PACUs. However, especially in hospitals with a large number of surgical emergencies, the scope of tasks and procedures within the PACU has expanded. Facing restricted capacities in ITUs and HDUs, the PACU serves as a buffer; intensive care functions can be covered here until the patient can be admitted to an ITU. In this context, the PACU also has a switch function; postoperatively, the patient is evaluated here and the level of further treatment determined: ITU, HDU or normal ward. The PACU period can be used to improve the patient's condition (upgrade function), enabling continuation of treatment at a lower level (HDU instead of ITU; normal ward instead of ITU). This combination of buffer, switch and upgrade function is of special importance when ITU and HDU resources are limited. A new task for the PACU arises from efforts to optimize acute pain therapy; initial adjustment of continuous infusion systems according to the patients' needs can be performed here without additional staffing requirements. Finally, the PACU can be used pre-operatively for 'tune up' procedures in high-risk patients.