COVID-19 prompts consideration of pre-ICU care

An expert calls for solutions to delays and boarding.

Waits for ICU beds, while common under normal circumstances, have been exacerbated by the COVID-19 pandemic, according to Kusum Sara Mathews, MD, MPH, MSCR.

For critically ill patients admitted through the ED, a spot in a ward or stepdown unit is sometimes used as a pre-ICU stopgap measure, or patients may be boarded in the ICU when there are no critical care beds available, Dr. Mathews said in a lecture at the American Thoracic Society's annual meeting, held virtually in August.

“Now imagine this course for your patients with COVID. . . . The pre-ICU course would have perhaps been abbreviated. The patient would have been quickly escalated into a negative-pressure room for isolation reasons. Or perhaps your hospital's already overrun and there are no isolation rooms available, and the wait will end up being prolonged,” she said. “In either case, pre-ICU course is something that we have to consider and we have to fix.”

There are about 6 million ICU admissions each year in the U.S., and approximately 20% of hospitalizations involve an ICU stay at some point, said Dr. Mathews, who is an assistant professor of pulmonary, critical care, and sleep medicine and of emergency medicine at Icahn School of Medicine at Mount Sinai in New York City.

Boarding of patients destined for the ICU is common. In a national survey of emergency medicine physicians published by the Western Journal of Emergency Medicine in February, 72% reported regularly caring for ICU boarders in the ED, and a cross-sectional study of ED boarding practices in the U.S., published by Academic Emergency Medicine in 2014, found that about 30% of patients admitted to the ICU were boarded for longer than two hours. “Now, this doesn't seem very long when taken in aggregate—until you consider that at many institutions, especially those in urban settings, the range of boarding can exceed 24 hours,” Dr. Mathews said.

In general, transit through the ED and hospitalization as a whole is slower for more complex, sicker, and older patients, Dr. Mathews noted. “We have to wait for more diagnostic studies to decide disposition, and patients require more complex discharge planning, needing [skilled nursing facilities] and rehabs instead of just going home,” she said. Delays in discharge then lead to longer waits for the outgoing ICU patients and bed crunches for the incoming critically ill.

Research on whether these delays affect outcomes has been mixed, Dr. Mathews said, with some studies finding an association between delayed ICU admission and mortality and others finding no link. The seeming contradictions in the literature might be explained by the resources available at the study sites, Dr. Mathews said, with some EDs and wards being better or worse equipped to handle critically ill patients than others.

The pandemic has put additional stress on already-stressed systems. As of July 30, Dr. Mathews said, the CDC had tracked 4.4 million COVID-19 cases and greater than 150,000 deaths. (In early September, those numbers had increased to more than 6 million cases and more than 184,000 deaths.) Hospitalizations related to COVID-19 were rising in certain parts of the country. “According to the CDC tracker across the country [as of July 14, when CDC tracking of these statistics ceased], 61% of the ICU beds are occupied, many by COVID patients. With limited ICU beds, the overflow of critically ill patients to non-ICU spaces is already occurring or inevitable in many places,” she said.

With hospitals planning for pre-ICU critical care delivery out of necessity, Dr. Mathews said, physicians should capitalize on the chance to rethink these processes. “After the dust settles with the COVID surge, this is our opportunity to look how to improve the care of the patient brought in by [emergency medical services], boarding in the ED or wards, and still waiting for that ICU bed,” she said.

The best fixes are made at the institutional level, Dr. Mathews said. Process mapping using Lean principles and operation management tools can help improve understanding of ICU bed allocation, as well as patient throughput, she said. Dr. Mathews recommended that physicians also consider clinical context by trying to answer such questions as, “How busy is my hospital? How many other patients are waiting for an ICU bed? [For] the patients waiting to leave my ICU, are there only specific places that they can go based on staffing, isolation, or telemetry needs?”

In addition, don't forget nonclinical factors that can lead to inefficiencies, Dr. Mathews said. “These include turn-over and patient transport, emptying that ward bed by getting patients their prescriptions earlier so they can transfer patients out of the MICU.” In addition, she said, physicians may need to consider institutional priorities, such as reserving ICU beds for certain postoperative cases or outside hospital transfers. “The problem is, if we don't open beds in the ICU, patients stay in this pre-ICU space longer without necessarily access to comparable resources of an ICU setting,” she said.

Effective solutions may include different or augmented models of care delivery based on the staffing and resources at each institution, Dr. Mathews noted. “At the end of the day, using these lessons we've learned in COVID, we need to approach care delivery in the pre-ICU space by balancing cost to the system with the more important priority of looking at the patient benefit,” she said, “and trying to decrease the risk of poor outcomes in this vulnerable patient population of the critically ill.”