More than half of intensive-care unit (ICU) patients (53 percent) at one large teaching hospital would have received more appropriate care in a different, less intensive setting.

The study, led by Dong Chang, MD, MS, and published in JAMA Internal Medicine analyzed a year’s worth of ICU admissions at his Harbor-UCLA Medical Center in Los Angeles. Each admission was assigned a priority rank based on Society of Critical Care Medicine (SCCM) guidelines:

• Priority 1: Critically ill, needing intensive treatment and monitoring that cannot be provided outside of ICUs.
• Priority 2: Not critically ill, but requiring close monitoring and potentially immediate intervention.
• Priority 3: Critically ill, but reduced likelihood of recovery because of underlying diseases or severity of acute illness.
• Priority 4: Not appropriate for ICU; equivalent outcomes achievable with non-ICU care based on low risk of clinical deterioration, presence of irreversible illness, or imminent death.

A fifth category was added for this study for patients who were awaiting transfer out of the ICU.

Out of more than 800 admissions, 46.9 percent were classified as priority 1, leaving the remaining 53 percent spread among patients who could have received adequate care outside the expensive ICU setting. Some 23.4 percent of admissions were categorized as priority 2, 20.9 percent as priority 3 and 8.8 percent as priority 4.

“Our findings suggest that ICU care is inefficient, devoting substantial resources to patients less likely to benefit,“ Chang and his coauthors wrote.

Deciding whether ICU is the appropriate care setting isn’t easy, Chang added, taking into account what patients want and hospital resources both in and out of the ICU, which limits how well the study can judge between what care is necessary and what isn’t. Additionally, the single-center nature of the research leaves plenty of room for different results at other facilities.

All hospitals could benefit, Chang argued, by more closely following SCCM guidelines.

“Categorizing ICU admissions by priority ranks identified opportunities to improve allocation of ICU resources at our institution,” Chang and his coauthors wrote. “Other hospitals could use this approach to improve the efficiency of their ICU utilization.”