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Over-Utilization of Non-Beneficial Invasive Procedures in Critically Ill Patients
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A4576 - Over-Utilization of Non-Beneficial Invasive Procedures in Critically Ill Patients
Author Block: C. K. Hwe, B. Berry, O. Stens, D. W. Chang; Medicine, Harbor-UCLA Medical Center, Torrance, CA, United States.
RATIONALE:
Overutilization of intensive care unit (ICU) treatments among patients with advanced medical illnesses can lead to invasive care that does not improve clinical outcomes. The objective of this study was to characterize how frequently invasive treatments are delivered when clinicians believe patients are unlikely to benefit from ICU care.
METHODS:
Patients admitted to the medical ICU of an academic safety net hospital were studied for 4 consecutive months (N=288). ICU physicians were asked to prospectively categorize all patients on each day of their ICU stay based on projected likelihood of benefit using guidelines from the Society of Critical Care Medicine as follows. Category 1: critically ill, needing intensive treatment and monitoring that cannot be provided outside of the ICU; Category 2: not critically ill, but requiring close monitoring and potentially immediate intervention; Category 3: critically ill, but unlikely to have meaningful recovery because of underlying diseases or severity of acute illness; and Category 4: not appropriate for ICU because equivalent outcomes achievable with non-ICU care. We examined the proportion of invasive ICU treatments delivered to patients despite being assessed by clinicians to have low likelihoods of meaningful recovery (Category 3) on the day of treatment. Data on invasive treatments were collected by chart review of the electronic health record system.
RESULTS:
Among 288 ICU patients, 50 (17.4%) were categorized by clinicians as having reduced likelihoods of meaningful recovery (42 patients were Category 3 on admission and 8 patients became Category 3 during ICU stay). In this group, 35 patients (70%) died, 13 (26%) were discharged with severely compromised functional states, and 2 (4%) were discharged home. Of 1402 ICU patient-days during the study period, 332 (23.7%) were Category 3. Among invasive treatments, 40.7% of patient-days for mechanical ventilation (307 out of 754), 51.5% of patient-days for vasopressors (157 out of 305), 40.7% of patient-days for renal replacement therapy (33 out of 81), 36.5% of central venous catheters (27 out of 74), and 30.8% of thoracenteses and paracenteses (4 out of 13) were performed in patients that were Category 3 on the day of treatment.
CONCLUSION:
Invasive ICU treatments are frequently delivered to patients despite clinicians’ impressions that they may not benefit patients. Studies that examine root causes for this pattern of utilization are needed to improve the quality and efficiency of ICU care.
Author Block: C. K. Hwe, B. Berry, O. Stens, D. W. Chang; Medicine, Harbor-UCLA Medical Center, Torrance, CA, United States.
RATIONALE:
Overutilization of intensive care unit (ICU) treatments among patients with advanced medical illnesses can lead to invasive care that does not improve clinical outcomes. The objective of this study was to characterize how frequently invasive treatments are delivered when clinicians believe patients are unlikely to benefit from ICU care.
METHODS:
Patients admitted to the medical ICU of an academic safety net hospital were studied for 4 consecutive months (N=288). ICU physicians were asked to prospectively categorize all patients on each day of their ICU stay based on projected likelihood of benefit using guidelines from the Society of Critical Care Medicine as follows. Category 1: critically ill, needing intensive treatment and monitoring that cannot be provided outside of the ICU; Category 2: not critically ill, but requiring close monitoring and potentially immediate intervention; Category 3: critically ill, but unlikely to have meaningful recovery because of underlying diseases or severity of acute illness; and Category 4: not appropriate for ICU because equivalent outcomes achievable with non-ICU care. We examined the proportion of invasive ICU treatments delivered to patients despite being assessed by clinicians to have low likelihoods of meaningful recovery (Category 3) on the day of treatment. Data on invasive treatments were collected by chart review of the electronic health record system.
RESULTS:
Among 288 ICU patients, 50 (17.4%) were categorized by clinicians as having reduced likelihoods of meaningful recovery (42 patients were Category 3 on admission and 8 patients became Category 3 during ICU stay). In this group, 35 patients (70%) died, 13 (26%) were discharged with severely compromised functional states, and 2 (4%) were discharged home. Of 1402 ICU patient-days during the study period, 332 (23.7%) were Category 3. Among invasive treatments, 40.7% of patient-days for mechanical ventilation (307 out of 754), 51.5% of patient-days for vasopressors (157 out of 305), 40.7% of patient-days for renal replacement therapy (33 out of 81), 36.5% of central venous catheters (27 out of 74), and 30.8% of thoracenteses and paracenteses (4 out of 13) were performed in patients that were Category 3 on the day of treatment.
CONCLUSION:
Invasive ICU treatments are frequently delivered to patients despite clinicians’ impressions that they may not benefit patients. Studies that examine root causes for this pattern of utilization are needed to improve the quality and efficiency of ICU care.
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