Clinical Investigations Survival of critically ill patients hospitalized in and out of intensive care units under paucity of intensive care unit beds* Elisheva Simchen, MD, MPH; Charles L. Sprung, MD; Noya Galai, PhD; Yana Zitser-Gurevich, MD, MPH; Yaron Bar-Lavi, MD; Gabriel Gurman, MD; Moti Klein, MD; Amiram Lev, MD; Leon Levi, MD; Fabio Zveibil, MD; Micha Mandel, MA; George Mnatzaganian, RN, MPH A shortage of beds in intensive care units (ICU) is a perceived problem in many countries where critically ill patients, who in the past succumbed, are now sur- viving (1, 2). Their number is greater than available ICU beds (3, 4). Even in countries such as the United States, where the number of ICU beds is more abundant, there is some shortage of beds, with critically ill patients sometimes be- ing treated in regular departments (4 – 6). The number of ICU beds required is often based on theoretical calculations rather than actual patient data (7–9). A recent study in Britain estimated a two-fold in- crease in the number of ICU beds re- quired for a region, using reports from hospital departments on patients eligible for intensive care (10). In Israel, the pro- portion of allocated ICU beds out of the total number of acute care hospital beds is only 2.0% (11), similar to proportions reported in Europe (12). In addition, not all the allocated ICU beds are operative due to a shortage of nursing staff. Despite the a priori notion that the ICU provides the best treatment for crit- ically ill patients with a great expenditure of resources, there are few studies docu- menting an improved survival of similar patients admitted to these units rather than to regular departments. The major- ity of studies of ICU triage and admission have focused on the in-ICU population (4, 5, 13) or patients admitted to or rejected from the ICU (14 –17), which prevented comparisons with all critically ill patients being cared for outside the units. The present study compares three dif- ferent types of hospital departments. First are respiratory/general intensive care units, where only intensivists direct and are responsible for patient manage- ment. The nurse/patient ratio in these units is one nurse per two patients. The second type includes various other spe- cial care units (SCUs) including postop- erative recovery rooms, coronary inten- sive care units, and neurosurgical and medical special care beds. In these units, patient management is the responsibility of surgeons, internists, cardiologists, and *See also p. 1791. From the Department of Health Services Research (ES, NG, YZ-G, MM, GM), Ministry of Health, Jerusa- lem, Israel; School of Public Health and Department of Anesthesiology and Critical Care Medicine (CLS), Ha- dassah-Hebrew University Medical Center (ES, YS-G), Jerusalem, Israel; Department of Epidemiology, SPH Hopkins University (NG); Department of Neurosurgery (YB-L, LL), Rambam Medical Center, Haifa, Israel; ICU (GG, MK), Soroka University Medical Center, Beer- Sheva, Israel; ICU (AL), Haemek Hospital, Afula, Israel; and ICU (FZ), Western Galilee Hospital, Naharya, Israel. Supported, in part, by the Ministry of Health, State of Israel. Copyright © 2004 by the Society of Critical Care Medicine and Lippincott Williams & Wilkins DOI: 10.1097/01.CCM.0000133021.22188.35 Objective: The demand for intensive care beds far exceeds their availability in many European countries. Consequently, many critically ill patients occupy hospital beds outside intensive care units, throughout the hospital. The outcome of patients who fit intensive care unit admission criteria but are hospitalized in regular wards needs to be assessed for policy implications. The object was to screen entire hospital patient populations for crit- ically ill patients and compare their 30-day survival in and out of the intensive care unit. Design: Screening teams visited every hospital ward on four selected days in five acute care Israeli hospitals. The teams listed all patients fitting a priori developed study criteria. One-month data for each patient were abstracted from the medical records. Setting: Five acute care Israeli hospitals. Patients: All patients fitting a priori developed study criteria. Interventions:None. Measurements and Main Results: Survival in and out of the intensive care unit was compared for screened patients from the day a patient first met study criteria. Cox multivariate models were constructed to adjust survival comparisons for various con- founding factors. The effect of intensive care unit vs. other de- partments was estimated separately for the first 3 days after deterioration and for the remaining follow-up time. Results showed that 5.5% of adult hospitalized patients were critically ill (736 of 13,415). Of these, 27% were admitted to intensive care units, 24% to specialized care units, and 49% to regular depart- ments. Admission to an intensive care unit was associated with better survival during the first 3 days of deterioration, after we adjusted for age and severity of illness (p  .018). There was no additional survival advantage for intensive care unit patients (p  .9) during the remaining follow-up time. Conclusions: The early survival advantage in the intensive care unit suggests a window of critical opportunity for these patients. Under economic constraints and dearth of intensive care unit beds, increasing the turnover of patients in the intensive care unit, thus exposing more needy patients to the early benefit of treat- ment in the intensive care unit, may be advantageous. (Crit Care Med 2004; 32:1654 –1661) KEY WORDS: intensive care unit, survival; prevalence; intensive care unit admission criteria; triage 1654 Crit Care Med 2004 Vol. 32, No. 8