Critical care units (CCUs) are an important part of any hospital. Typically, between 8% and 12% of a hospital's beds are devoted to some form of critical care (about 3% outside the US), which consumes half of an institution's direct patient care budget; CCUs are expensive.

A standard indicator for hospital patient flow problems are ED diverts and boarding. In 2004 46% of all hospitals reported going on ambulance diversion; that percentage goes up to 69% for urban hospitals. Similar data for 2001 shows the rates of diversion at 62% and 79%; this represents some improvement, but not much. The leading cause of this patient flow backup: lack of critical care beds (2001 and 2004, 43% and 39% respectively). While the number of ICU beds grew 26% between 1985 and 2000, the problem still exists.

In addition to constrained capacity, there is also a problem with over utilization. Critical care areas see a high degree of inappropriate admissions that take beds away from truly critically ill patients. In one study, "11% to 34% of patients admitted to the ICU in the past two quarters alone did not meet the severity and intensity measures, justifying admission to the ICU." An inappropriate admission to ICU, being the most expensive, can produce significant unreimbursed costs to the hospital if the payer deems the admission inappropriate. With capitated patients, a hospital gets just so much per admission. Even if the patient met criteria for admission, it is prudent to treat the patient with what he/she needs, no more and no less. An ICU admission might be too much. In most cases, these inappropriate admissions end up in CCUs (especially Telemetry and stepdown units) because they require patient monitoring or a nurse-to-patient ratio that is higher than that available in general care areas.

It is unlikely that hospitals will build their way out of this problem. Well over half of US hospitals have negative patient care margins, and ICUs are expensive to build and deliver care ($2,674 per patient day).

The "acuity adaptable" room is a concept that has been gaining ground as a strategy to relieve pressure on critical care areas. Health Facilities Magazine has an article on trends in CCU construction and leads off with a discussion of variable acuity or universal beds. The term "universal bed" (universal room or universal unit) is traditionally defined as private patient rooms equipped to the standards required for critical care. Here's an explanation from the article:

Universal room construction involves equipping private patient rooms to the standards required for critical care, under the assumption that as the patient recovers, he or she will be permitted to stay in the same room while the trained staff rotate. Nurses' stations are positioned immediately outside the patient room with patient viewing windows, electronic charting and digital information--one nurses' station per two private patient rooms.

This I think is misguided. Building out a meaningful percentage of patient rooms in this way would create a greater number of expensive ICU-type rooms that would only be used as critical care rooms for a portion of the time they are in use. If the nurse-to-patient ratio is maintained at 1:1 or 1:2, HPPD (hours per patient day) costs would also equal the ICU. These rooms could be even more expensive than traditional ICU rooms if current "state of the art" recommendations of additional nursing stations and amenities for family members are included.

Nor is the implementation of "universal beds" simple to implement:

Though architects and administrators have embraced the acuity-adaptable configuration in many settings, it is most appropriate in critical care, where the desired nurse-to-patient staffing ratio is maintained at 1:1 or 1:2. It is far less efficient in medical-surgical nursing units, where the nurse-to-patient ratio may be 1:4 or 1:5.

The challenge for providers is successfully staffing the acuity-adaptable model. Critical care nurses require specialized training and possess specialized skill sets. What happens when one of the two critical care patients becomes less acute? The critical care nurse, positioned outside two universal rooms, is now faced with caring for one critically ill patient and one lower acuity patient, which is inefficient and expensive.

The description above seems to recommend an approach of providing a greater than necessary level of care in the most expensive setting. This seems a non-starter given today's health care costs, the state of hospital finances, reimbursement pressures, and changing patient

What is needed is the creation of true variable acuity units that are different from both critical care and med/surg units. The guiding philosophy of such a unit is to deliver the appropriate level of care in the least expensive environment. This approach preserves both patient safety and hospital finances. Typical variable acuity unit policies include:

  • Critical patients (that meet admissions criteria) continue to be cared for in ICUs
  • The variable acuity unit replaces some or all traditional Telemetry, high dependency and stepdown units
  • No special construction or build-out is required, but appropriate patient surveillance and alarm notification is required
  • Admissions requirements are defined for the variable acuity unit, and revised for other units (and enforced!)
  • Variation of patient acuity supported by a variable acuity unit ranges from a high dependency or stepdown unit to general care
  • A nursing staff with a broader mix of skills is required, i.e., some critical care nurses and some med/surg nurses
  • Patient assignments and nurse-to-patient ratios will be driven by either patient acuity or workload and vary by patient
  • Multi parameter patient monitoring is available in the unit
  • Appropriate meds and therapies (IV, vents, etc.) are available on the unit

The goals of the variable acuity unit are to:

  • Allow patients that do not require 1:1 or 1:2 nursing care to bypass CCUs
  • Allow patients to be discharged from the ICU more quickly and placed in an appropriate and lower cost setting
  • Reduce readmission to the CCUs when patients require greater clinical surveillance or intervention
  • Provide greater continuity of care, as patients are transferred less between "specialized" units
  • Reduce LOS, mostly as a consequence of fewer transfers
  • Free up CCU beds and significantly reduce ED diversions and boarding

This past May, an editorial in the Am Journal of Critical Care called for fewer ICU beds in the US, observing that many patients who are placed in an ICU to receive a little extra care and observation could receive the care they need in a unit with a lower but appropriate level of management. A variable acuity unit is a thing unto itself, not an ICU with lower acuity patients nor a med/surg unit with patient monitors. The creation of a flexible acuity unit, as opposed to a universal unit, provides significant financial and clinical benefits.