Clinical Research—Adult
Mechanical ventilation of patients hospitalized in medical wards vs the intensive care unit—an observational, comparative study

https://doi.org/10.1016/j.jcrc.2006.06.004Get rights and content

Abstract

Background

In some hospitals, patients are mechanically ventilated on the wards in addition to the intensive care unit (ICU) because of the shortage of ICU beds.

Objective

The aim of the study was to compare the outcome and ventilatory management of medical patients mechanically ventilated on the medical wards and in the ICU.

Design

This was a prospective, observational, noninterventional study over a 6-month period.

Setting

The study was conducted in internal medicine wards and the ICU of a 500-bed community university-affiliated hospital.

Patients

Ninety-nine mechanically ventilated medical patients in the ICU or on the medical wards because of shortage of ICU beds were included in the study.

Results

Baseline characteristics of the patients ventilated in the ICU (group 1) and in the medical wards (group 2) were collected. Thirty-four patients were ventilated in the ICU and 65 in the wards during the study period. In-hospital survival rate in group 1 was 38% vs 20% in group 2 (P < .05). The Acute Physiologic and Chronic Health Evaluation (APACHE) II score in group 1 was 24 ± 7 vs 27 ± 7 in group 2 (P < .05). Other prognostic factors were similar. The age of the survivors in the 2 groups was similar: 57 ± 25 years in group 1 vs 69 ± 13 years in group 2 (P = NS). Mean number of ventilatory changes in group 1 was 7.5 ± 1.4 per day per patient, whereas it was 1.3 ± 1.0 in group 2 (P < .001). The number of arterial blood gas analyses in group 1 was 7.7 ± 1.2 per day per patient compared with 2.3 ± 1.3 in group 2 (P < .001). Twenty percent (20%) of the patients in group 1 had endotracheal tube–related inadvertent events compared with 62% of the patients in group 2 (P < .05).

Conclusions

We conclude that in medical patients requiring mechanical ventilation, there is a higher in-hospital survival rate in ICU-ventilated patients as compared with ventilated patients managed on the medical wards. In addition, ICU provides a better monitoring associated with less endotracheal tube–related complications and more active ventilatory management.

Introduction

The shortage of intensive care unit (ICU) beds is a daily problem in many hospitals around the world [1], [2], [3]. Therefore, the “gate keeper” of the ICU is often confronted with the difficult decision of choosing between patients who are believed to benefit from the ICU and those patients who are either “too sick” (the chance of survival will likely not improve by ICU care) or “too healthy” (require monitoring only and will not require ICU treatments) for the ICU. As no accurate individually valid scoring system has been developed for triaging ICU patients, these decisions are extremely difficult, and at times are based upon clinical impression and experience [4], [5]. These decisions, especially when ICU beds are limited, necessarily result in rejection of patients from being treated in the ICU.

This issue may be even more problematic in medical patients. Medical patients have not undergone an operation and do not “automatically” commit the hospital system to aggressive patient management, including ICU admission, in contrast to surgical patients. Surgical patients who need mechanical ventilation after surgery have a preferred access to our ICU, if not for other reason, then in order not to block the postanesthesia recovery room. Therefore, it seems that many more medical patients, compared with surgical, are ventilated on the regular medical wards and not in the ICU when ICU bed shortage is prominent. The literature regarding these patients is very limited, and there is very scarce data on the outcome of these patients [6], [7].

As early as 20 years ago, the management of long-term ventilator-dependent patients in specially assigned units compared with the wards was assessed to be superior in such units [8]. This same notion most probably applies to immediately ventilated patients. Although it is intuitively perceived that applying mechanical ventilation for treating acute respiratory failure outside the ICU is associated with significant morbidity and mortality, this procedure is routinely done in Israel and many other countries because of the shortage of expensive ICU beds. There are very few studies comparing outcome of ventilated patients in the ICU to those who should be in the ICU but are ventilated on the ward because of ICU bed shortage [6], [7]. We therefore conducted a prospective observational comparative survey of medical patients who required mechanical ventilation and were hospitalized on the medical wards vs the ICU to compare in-hospital mortality and the ventilatory management of both groups. Although expected, the results of such a study may help convincing health management policy leaders to expand ICU bed number, in our country and other countries.

Section snippets

Setting

The Shaare Zedek Medical Center (Jerusalem, Israel) is a 500-bed university-affiliated hospital, operating with a 6-bed general, mixed (surgical and medical) ICU and 4 medical wards scattered on 2 different floors.

Time and design

The study was an observational comparative study from January to June 2004 (6 months). No patient had any intervention or treatment performed as part of the study nor identified in person. Accordingly, our local Helsinki committee waived informed consent.

Inclusion criteria

All medical patients in the

Results

Ninety-nine consecutive patients qualified for the study. Thirty-four (34%) were admitted to the ICU (group 1) and 65 (66%) were admitted to the medical wards (group 2) (Table 1). The male-female ratio was similar in both groups. Twenty-two other patients were screened and excluded from the study because of no predictable ICU benefit/DNR (n = 11), transfer from the ward to the ICU (n = 5), or transfer from ICU to the wards (n = 6).

Thirty-eight percent of the patients in the ICU (group 1)

Discussion

The need for additional ICU beds is seemingly a constant problem. Unfortunately, these beds are highly expensive and their number in various countries, and even in the same country, differs according to local resource availability and allocation. Although it is generally accepted that an ICU bed is more effective in “saving lives” of critically ill patients than a bed on a general ward, because of the higher cost of these beds there is still a shortage of ICU beds. In the United States the

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1

Affiliated with the Ben-Gurion University of the Negev (Beer Sheva).

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