Utilization strategies for intensive care units

Abstract

Critical care resources in the United States are being rationed, that is, not all critical care expected to be beneficial is being provided to all patients who desire it. Although the extent of rationing is uncertain, it is an everyday occurrence in some hospitals and is likely to occur at least some of the time in many hospitals. Substantial evidence suggests that current rationing practices are highly subjective and perhaps inequitable. Critical care is widely believed to be beneficial to many patients, despite a striking dearth of supportive data. Since this type of care is being inequitably denied to some patients, hospitals should either adopt formal rationing guidelines or, alternatively, they should take clear steps to avoid rationing by altering the supply of or the demand for critical care. Reasonable arguments are presented in support of both approaches, as are suggestions for their implementation.

KIE: Considerable evidence supports the contention that U.S. hospitals ration critical care resources in an informal, often irrational and unfair manner. The value, efficacy, and cost of intensive care units are discussed and two options are proposed to tackle the problem of rationing. Hospitals should either establish formal, specific, and equitable rationing guidelines or, alternatively, develop plans to avoid rationing by increasing the supply of resources or by decreasing the demand for them. It is suggested that demand be decreased by more aggressive discharge or by a system of graded care rather than by denying admission. Arguments in favor of and against rationing are presented. It is concluded that, whichever option is chosen, plans should be developed openly, approved by appropriate supervisory bodies, and brought to the attention of hospital staff and patients.