Evaluation of appropriateness of intensive care unit admissions: the GIVITI's StART approach

Introduction

Appropriate use of ICU resources is mandatory. When a patient is admitted to a unit able to provide a higher (lower) level of care than required, a waste (overuse) of resources can be advocated. StART is an approach to identify possible mismatches between the level of care actually delivered, assumed to correspond to what is clinically required, and the level of care deliverable by the unit.

Methods

ICU beds are classified by levels of care deliverable as High (ventilator, monitor, and 720 minutes nurse time) and Low (monitor and 360 minutes nurse time) [1]. The level of care actually delivered is classified as High (invasive or non-invasive ventilation, or two vasoactive drugs, or at least two of the following: one vasoactive drug, dialysis, respiratory support), Low (single vasoactive drug, or dialysis, or respiratory support) and Ordinary (none of the above) [2]. Mismatches between the level of beds available and the level of care delivered were evaluated both on admission and for each ICU-day of 4,237 patients in 28 ICUs. An ICU-day was judged as inappropriate, even without mismatch, if an Ordinary patient was present.

Results

Eighteen percent of admissions resulted inappropriate (9% overuse, 9% waste of resources). Patients receiving H level of care (58% of the total) were appropriately admitted in 88% of cases. There were 271 patients admitted for Ordinary care (6%). They stayed in the ICU 2.5 days on average, and 95% of them had no complications. Sixty-eight percent of the ICU-days were inappropriate: 12% for overuse and 56% for waste of resources. Forty-two percent of the latter days were only due to the presence of Ordinary patients (43% of them were instead admitted as H or L patients).

Conclusions

Most of the ICU admissions (82%) were appropriate; the inappropriateness was mostly due to Ordinary patients treated. The short ICU stay and the absence of complications of these patients strengthen the inappropriateness of their admission, which was probably due to the lack of intermediate care units in Italy. The situation is completely different considering the ICU stay: the inappropriateness rose up to 68%, mainly due to the presence of Ordinary patients. Almost one-half of them were patients recovered from sicker condition, who were probably difficult to discharge from the ICU.