Editorial
July 10, 2023
Intensive Care Unit Transfer Decisions—Science or Art?
Tracy Y. Wang, Tyrone A. Johnson, Mitchell H. Katz
JAMA Intern Med. Published online July 10, 2023. doi:10.1001/jamainternmed.2023.2636
For many hospital-based clinicians, one of the most consequential triage decisions is whether to transfer a high-risk patient from a regular medical-surgical bed to the intensive care unit (ICU). Despite its importance and frequency, there is relatively little research guiding ICU triaging. On the other hand, we know these triage decisions are often affected by factors other than patient acuity, such as limited supply of ICU beds and nursing ratios in non-ICU settings.1,2
A study in this issue of JAMA Internal Medicine illustrates the subjective nature of ICU transfer.3 In their 5-hospital study, Doshi et al3 found that patients were more likely to be transferred to the ICU if another patient had had a critical illness event on the same ward (adjusted odds ratio, 1.39; 95% CI, 1.30-1.48) in the prior 6-hour period compared with no such event. However, the risk of death was not higher for the subsequent patient transferred. We cannot know for certain why that second patient was transferred. Certainly, increased vigilance after a previous catastrophic event is one possibility (anchoring bias). Increased availability of staffed ICU beds explaining the clustering of patient transfers is another possibility, although the authors’ negative control analysis found that there was no significant association between ICU transfer in one ward and ICU transfer from another ward, suggesting that it is not just ICU bed availability that affects the difference. But we can now add ICU triage subjectivity, or conversely interclinician variability in comfort treating patients at high risk on wards, to the list of nonacuity-related factors that determine whether patients are transferred to an ICU.4,5
The ICU is a multidimensional intervention that differs from floor beds in several major ways: higher ratio of nurses to patients, the geographic colocation of critically ill patients for closer surveillance and access to advanced life support, better-equipped rooms that permit more extensive physiologic monitoring and rapid intervention, and staffing by health professionals with critical care expertise. Nurse to patient ratios vary by hospital and state (California and Massachusetts being the only states with mandated minimum ratios), although studies report an average nurse to patient ratio of 1:2 for critical care and 1:6 for medical-surgical floor care6,7; lower nurse to patient ratios have additionally been associated with increased mortality.7,8 Intensive care units that are consistently staffed by health care professionals with critical care expertise (eg, closed ICUs, ICUs mandating intensivist consultation) are also associated with lower ICU and hospital mortality and length of stay.9,10
Many of these ICU advantages can be replicated in regular hospital wards where remote monitoring is already widely prevalent. The Institute for Healthcare Improvement endorses the deployment of early warning systems and rapid response teams to promote patient safety in hospital settings.11 Early warning systems use objective, physiologic risk-prediction tools in general medical-surgical units to help staff recognize patients at high risk before their condition deteriorates. To keep patients on the floor, nurses could be assigned fewer of them when they are faring poorly or need closer attention. However, flexibility in nurse staffing is often limited, and the need for closer nursing supervision is one of the most common reasons for ICU transfers. With algorithmic activation of rapid response teams, composed of clinicians with critical care expertise that can proactively deliver more intensive monitoring and care to the bedside, hospitals may successfully alter the patient’s clinical trajectory and in some cases avoid ICU use.
Intensive care unit transfers disrupt continuity of care; ICU care is, by design, resuscitative and invasive, and its environment is not particularly conducive to rehabilitation and recovery. Hospitals bill higher rates for ICU care. If that rate leads to better outcomes and is consistent with patient and family wishes, that is appropriate. But to the extent that ICU triage decisions are not based on the actual needs of the patient, ICU care may make care more expensive without increasing its value. There are many other patient-centered reasons why ICUs may not be the preferred setting of care. In this regard, the question is best stated as what level of care do patients need (and want) to improve their quality of life? At times, a time-limited trial of intensive care may be appropriate.12
