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The application of advances in health IT that can be used to triage decisions in intensive care units (ICUs) could be a “most promising approach” to counteracting some problems with ICU processes, according to a perspective published Jan. 31 in the New England Journal of Medicine .
The authors did exemplify the Veterans Affairs Healthcare System and Kaiser Permanente Northern California as having the capabilities of EHRs to generate reliable estimates of the risk of death within 30 days for every patient on admission. “Yet, these calculations of risk, which may combine real-time data on laboratory results, demographics, coexisting conditions, and vital signs, are not being used to inform decisions about admission to the ICU,” they wrote. To accelerate progress in this area, we believe that more targeted incentives for Meaningful Use of health IT should be considered.”
Lena M. Chen, MD, of the department of internal medicine at the University of Michigan and the VA Health Services Research and Development Center of Excellence, VA Ann Arbor Healthcare System, both located in Ann Arbor, and colleagues suggested that the triage of patients at the time of hospital admission is one such area ripe for study because triage decisions frame the subsequent course of care for all hospitalized patients. Yet, in the case of critical care admissions, they pointed out that these decisions “vary widely” among hospitals, which suggests that there is some misallocation of resources (Arch Intern Med 2012;172:1220-1226).
Reliable, individualized, EHR-based predictions of risk have the potential to the ability to triage—and hence care for—patients, they wrote.
To assess this hypothesis, Chen et al examined the records of a cohort of 101,912 patients admitted for reasons other than surgery to 121 VA acute care hospitals in 2009. The critical care guidelines maintain that the ICU is the place to care for “the most seriously ill patients,” they cited. Yet, for the most common noncardiac diagnoses, they found that, in keeping with this guideline, patients with a high severity of illness were much more likely to be admitted to the ICU than were patients with a low severity of illness. In sharp contrast, for common cardiac diagnoses, severity of illness played a negligible role in ICU-admitting decisions, they reported.
The authors suggested “a number of potential explanations” for these findings. Patients with cardiac illness may have a need for critical care that isn't captured by severity scores; however, they added that the VA's ICU severity score is “an excellent predictor” of the 30-day risk of death, with areas under the receiver-operating-characteristic curve of 88 percent for patients with cardiac illness and 81 percent for those with noncardiac illness.
Also, Chen and colleagues acknowledged that they did not have data on patients' palliative care decisions; and it's “possible” that patients with cardiac illness are overrepresented in the population of ICU patients who need telemetry, and were admitted to the ICU because of adherence to a protocol or are awaiting transfer to another facility with interventional capabilities.
“[T]aking care of the sickest patients is the only role that has been explicitly endorsed for the ICU,” wrote the study authors. “Use of the ICU for providers' convenience or peace of mind, as a temporizing measure for staffing problems, or as an all-purpose substitute for unavailable procedure or recovery rooms is unlikely to be an efficient use of valuable resources.”
These preliminary results, along with other research, suggest that “additional work is needed both to determine who benefits from critical care and to identify what indications for ICU use—other than severity of illness — have merit,” the authors noted. “A natural next step would be to examine whether ICU admission is associated with different condition-specific outcomes for low-risk versus high-risk patients, after accounting for patient preferences.”
Data from the EHR offer the chance to reexamine and improve the value of critical care, they noted. Incentives for reaching health IT targets related to patient triage could accelerate the research and collaboration necessary to take full advantage of this opportunity.
“It makes the most sense to use the ICU for the most seriously ill patients or those who stand to benefit the most from critical care and to harness the emerging power of the EHR across large health systems to evaluate how we can best