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Rationing Without Contemplation: Why Attention to Patient Flow Is Important and How to Make It Better

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Book cover The Organization of Critical Care

Part of the book series: Respiratory Medicine ((RM,volume 18))

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Abstract

Inattentiveness to patient flow leads to rationing of critical care without contemplation. Many ICUs today operate at the limits of their capacity, making daily decisions about which patients can receive critical care. Historically, hospitals have dealt with this by building additional ICU beds. However, improving patient flow effectively increases ICU capacity without building additional beds, and problems with patient flow have well-documented, harmful effects on patients both in the ICU and waiting for care in the ICU. A number of tools from manufacturing and operations research allow us to understand, measure, and model patient flow, and to use this understanding to make meaningful improvements in real-world ICUs.

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Notes

  1. 1.

    In healthcare, decisions about who the customer is can be complex (e.g., patient, payor, family members, etc.; sometimes another physician is the customer of a service), but we usually adopt the perspective of the patient as the customer. This is both simpler and, usually, clarifying in both a practical and ethical sense.

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Author information

Authors and Affiliations

  1. Center for Quality, University of Chicago Medicine, 850 E. 58th Street, Chicago, IL, 60637, USA

    Michael D. Howell

  2. Center for Healthcare Delivery Science, Division of Pulmonary, Critical Care and Sleep Medicine, Beth Israel Deaconess Medical Center, 330 Brookline Avenue, Boston, MA, 02215, USA

    Jennifer P. Stevens

Authors
  1. Michael D. Howell
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Correspondence to Michael D. Howell .

Editor information

Editors and Affiliations

  1. Division of Critical Care Medicine, University of Toronto, Toronto, Ontario, Canada

    Damon C. Scales

  2. Division of Critical Care Medicine, University of Toronto, Toronto, Ontario, Canada

    Gordon D. Rubenfeld

Case Study: Using Patient Flow to Improve Patient Care Without Building Beds

Case Study: Using Patient Flow to Improve Patient Care Without Building Beds

Beginning in 2006, our institution, an urban, tertiary care teaching hospital in Boston, Massachusetts, with 77 ICU beds and about 600 hospital beds, tackled a number of challenges to improve patient quality and flow. We worked sequentially on improving care for patients with sepsis [58], preventing central line infections, preventing ventilator-associated pneumonia, and implementing a rapid response team [59], along with other quality interventions. Additionally, we collaborated with other services in our hospital, particularly the emergency department and the medical floors, to reduce delays in the length of time ICU patients waited for beds on non-ICU floors [60].

The result was an improvement in ICU length of stay, ICU throughput and mortality (Fig. 11.3a–c). Earlier efforts to meet the clinical and patient level demand for ICU care had revolved around building additional beds, as seen in Fig. 11.3d, between 2004 and 2006. With the interventions described above, we were able to care for more than 1,000 additional ICU admissions per year, without building any additional ICU beds. In fact, our hospital had planned and budgeted for a capital expense of several million dollars to build a new ICU, but was able to avoid this expenditure entirely.

Fig. 11.3
figure 3

(a) ICU length of stay (average days per year). (b) ICU throughput (average patients per year). (c) In-hospital mortality rate (average, per year). (d) Change in patient capacity and bed capacity, compared with 2004 baseline

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Howell, M.D., Stevens, J.P. (2014). Rationing Without Contemplation: Why Attention to Patient Flow Is Important and How to Make It Better. In: Scales, D., Rubenfeld, G. (eds) The Organization of Critical Care. Respiratory Medicine, vol 18. Humana Press, New York, NY. https://doi.org/10.1007/978-1-4939-0811-0_11

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  • DOI: https://doi.org/10.1007/978-1-4939-0811-0_11

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  • Online ISBN: 978-1-4939-0811-0

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