Tuesday, May 10, 2005

Critically few beds

We all know it's true: if there is an influenza pandemic, we aren't ready for it. Among the things "not ready" means is not enough critical care beds in the hospital. But do we know what that means? A review over at Bandolier (the "evidence based" group at Oxford in the UK) spells it out:
Limited availability of healthcare resource in the face of permanent or temporary excess demand leads inevitably to rationing. Hardly news, that, though the R word is perhaps the hardest to use. Given that rationing is a fact of life, it behoves us to have some idea of the consequences. A systematic review of rationing of critical care beds tells us that more people die who might have lived.
This is a broad literature review on the consequences of rationing critical care beds. Papers included triaging studies that compared patients admitted to the Intensive Care Unit (ICU) with those not admitted; studies comparing patients admitted during at least two different periods, one of which was reduced bed availability; and studies of patients either admitted or refused admission during a single period of bed shortage. Ten studies met the criteria for rigor and informativeness.

Some results. In four of the triaging studies, 1220 patients admitted to ICUs were compared to 558 not admitted:
Overall mortality was 29% (357/1,220) in those admitted to ICU, compared with 50% (280/558) in those refused an intensive care bed (relative risk 1.7; 95% confidence interval 1.5 to 1.9). For every five patients refused an intensive care bed, one more died (95% CI 4 to 6) than would have been the case if they had been admitted to intensive care. [my emphasis]
Bandolier's bottom line: "Rationing comes with the price, for intensive care beds, of more deaths in those refused admission."

The current lack of planning for critical care bed surge capacity will cost lives if there is an influenza pandemic or other sudden demand. This isn't a surprising result. Although it was arrived at by surveying existing literature, assessed for reliability, it is also common sense.

But as we know, common sense isn't all that common.