A hospital in the US is trying to deal with bed shortages and spiralling costs by rethinking who gets into their ICUs. I suspect this is long overdue.
If I understand the system, you get put in an ICU if the doc looking after you (on the ward or in the ED) decides that you need one. And it seems a lot of these decisions are based on the diagnosis and not necessarily a real clinical need. (though I might be wrong on that).
This stands in sharp contrast to practice I’ve observed both in Ireland and in New Zealand.
You get into the ICU on the basis of a discussion/negotiation between the person looking after the patient and the intensivists. At the end of the day the intensivists get the final word.
They describe this as a closed system in the article.
Here are some pros and cons to a closed system:
- another, potentially more useful specialty (the intensivists) get involved in the patients care, and when you’ve got a real sickie they save your ass (and just maybe the patients)
- patients seem more likely to get in out of a genuine need rather than just having the label of say, DKA
- if you’re working as an intensivist then you get to give the drugs you want to give the way you want to give them
- on the ED side it can be a frustrating, difficult and sometimes heated discussion to get the patient admitted, you can be left with an intubated patient no-one is willing to take (more on that later)
- sometimes borderline patients go to the ward and not the unit because there’s not space. Admission criteria differ based on the occupancy, this is an inevitable but unfortunate reality. And it’s important to note that this may well happen in an “open” system and it’ll be you making that call not the intensivist
- if you’re the admitting medical team, the ICU team might do all kinds of shit you’d rather not. The old controversy like fluid management in DKA and oxygen use in COPD spring to mind in my experience