Chest
Volume 108, Issue 2, August 1995, Pages 490-499
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Clinical Investigations in Critical Care; Articles
The Use of Risk Predictions to Identify Candidates for Intermediate Care Units: Implications for Intensive Care Utilization and Cost

https://doi.org/10.1378/chest.108.2.490Get rights and content

Objective

To develop a predictive equation that estimates the probability of life-supporting therapy among ICU monitor admissions and to explore its potential for reducing cost and improving ICU utilization.

Design

Prospective inception cohort analysis.

Participants

Forty-two ICUs in 40 US hospitals with more than 200 beds and a consecutive sample of 17,440 ICU admissions.

Interventions

A multivariate equation was developed to estimate the probability of life support for ICU monitoring admissions during an entire ICU stay.

Measurements

Demographic, physiologic, and treatment information obtained during the first 24 h in the ICU and over the first 7 ICU days.

Results

The most important determinants of subsequent risk for life-supporting (active) treatment were diagnosis, the acute physiology score of APACHE III, age, operative status, and the patient's location and hospital length of stay before ICU admission. Among 8,040 ICU monitoring admissions, 6,180 (76.8%) had a low (<10%) risk for receiving active treatment during the ICU stay; 95.6% received no subsequent active treatment. Review of outcomes and the type and amount of therapy received suggest that most low-risk ICU monitor admissions could be safely cared for in an intermediate care setting.

Conclusion

Objective predictions can accurately identify groups of ICU admissions who are at a low risk for receiving life support. This capability can be used to assess ICU resource use and develop strategies for providing graded critical care services at a reduced cost. (CHEST 1995; 108:490-99)

Section snippets

Methods

This analysis is a part of the acute physiology and chronic health evaluation (APACHE) III study,21 an evaluation of severity and outcome in 42 ICUs at 40 hospitals. The entire data collection protocol was approved and the need for informed consent waived by the institutional review board at the George Washington University Medical Center, and also it was reviewed and approved at participating hospitals. The 40 participating hospitals included 26 nonfederal US hospitals with >200 beds selected

Characteristics of Hospitals, ICUs, and Patients

Among the 40 hospitals studied, 25 (63%) had residents or one or more accredited graduate medical training programs and 21 (53%) were affiliated with a medical school. Geographically, 17.5% were in the Northeast, 32.5% in the South, 30% in the Midwest, and 20% in the West. The mean number of hospital beds was 474 (range, 200 to 1,315 beds). The mean number of adult ICU beds at each hospital was 22 (range, 6 to 76 beds); and 25 hospitals (63%) had one or more intermediate care units. Among the

Discussion

Among 17,440 admissions to 42 ICUs at 40 US hospitals, we found that 8,040 patients (46%) received only technologic monitoring and concentrated nursing care during their first ICU day. Multivariate analysis indicated that risk for subsequent active life-supporting treatment among these monitoring admissions could be accurately predicted based on patient characteristics measured during the first ICU day. The predictors of risk for active treatment included diagnosis, the age and physiologic

ACKNOWLEDGMENTS

We acknowledge the data collection efforts and leadership of the hospitals involved in the APACHE III study.

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    Supported by the Agency for Health Care Policy and Research (HSO 7137), the Department of Anesthesiology, George Washington University Medical Center, and APACHE Medical Systems, Inc.

    APACHE and APACHE III are trademarks of APACHE Medical Systems (AMS), Inc. Drs. Knaus, Zimmerman, and Wagner are founders and shareholders of AMS, Inc, and are prohibited, by the University, from receiving any payment, royalties, or other fees from AMS. Elizabeth Draper, RN, MS, is an employee and shareholder of AMS. APACHE Medical Systems produces a management information system for critical care units, and holds the commercial copyright on the active treatment predictive equation and the APACHE III database. Although protected by commercial copyright, this equation is available to researchers for independent verification ana further analysis.

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