clinical investigations in critical care
Closure of an Intermediate Care Unit*
Impact on Critical Care Utilization
Robert J Byrick, M.D .; C. David Mazer; M .D .; and Gary M. Caskennette
We studied the effect of closing a six-bed intermediate care
area (ICA) on utilization of a multidisciplinary critical care
unit (CCU). Data were collected on all admissions to the 7-
bed CCU for 9 months prior to ICA closure (n=217) and
compared with 9 months after CCU expansion (7 to 9 beds)
and ICA closure (n=407). Nonemergency CCU admissions
increased from 41 to 112 after ICA closure (p<O.03). Mean
APACHE II score within 24 h of admission decreased from
21.9±7.4 to 18.6±7.4 (p<O.OOOI). The proportion of
patients with APACHE II score < IS, increased from 301
217 to 1361407 accounting for an increase from 5.4 percent
to 12.7 percent ofCCU days (p<O.OOOI). Nursing workload
The high cost of providing critical care has provoked
a variety of "utilization strategies" within hospitals
to optimize use of these scarce resources. I The relative
scarcity of critical care resources and limited access
to them is a result of both increasing demand and
restrained supply. One strategy that many hospitals
have adopted is the provision of "graded" levels of
care in intermediate care units to apportion nursing
time and monitoring facilities for specific patient
needs."? This strategy has been proposed as a cost-
effective alternative to critical care unit (CCU) admis-
sion, particularly for low-risk patients admitted for
monitoring,"
Most reports that evaluate the impact of an inter-
mediate level of care on the use of CCU resources do
so after the opening of an intermediate care area
(ICA).6.7 Few, if any, studies have evaluated the impact
of closing an ICA on the utilization of a multidiscipli-
nary critical care facility that services both medical
and surgical patients. The decision to admit patients
to the CCU for monitoring alone is controversial and
some tnvestigators'-" have suggested that many of these
patients could be safely cared for in an ICA.
A recent budgetary crisis in our adult, tertiary care
referral hospital resulted in a decision to close an
*From the Departments of Anaesthesia (Drs. Byrick and Mazer)
and Department of Biomedical Engineering (Mr. Caskennette),
St. Michael's Hospital, Toronto, Ontario. Canada.
Manuscript received October 9, 1992; revision accepted January 6
Reprint requests : Dr. Byrlck, Department of Anaesthesia, St.
Michael Hospital, 1bronto, Ontario, Canada M5B lW8
876
at the time of discharge from CCU decreased (p<O .OOOI).
The ICA closure altered CCU admission and discharge
decision-making. "Low-risk" admissions increased and pa-
tients remained in the CCU until they required less nursing
care. One factor determining utilization of a CCU is the
facilities available outside the unit. A CCU management
system is especially important when a wide range of illness
severity is present. (Chest 1993; 104:876-81)
leA = intermediate care area; TISS = Therapeutic Intervention
Scoring System
intermediate care unit that had served as a "step-
down" facility as well as a "low-risk" monitoring unit.
Our critical care audit system" permitted retrospective
analysis of the interaction of the structure and organ-
ization of hospital facilities with utilization of a multi-
disciplinary medical-surgical CCU.
METHODS
HospitallCCU
This study was conducted in St. Michael's Hospital, an adult,
tertiary care referral center affiliated with the University ofToronto .
All medical and surgical specialtie s were available in the hospital .
The medical/surgical CCU was a multidisciplinary unit , supervised
and staffed by a team of critical care physicians with residents
available in the unit 24 hid. Th e nursing managers provided one
nurse per patient during the time period s studied .
Indications for admission to the medical-surgical CCU included
the requirement for mechanical ventilatory support, critical care
nursing, and/or invasive hemodynamic monitoring not available in
other areas of the hospital . With the exception of postoperative
cardiac and neurosurgical patients and posttrauma patients who
were admitted to other specialized units, all patients requiring
critical care were admitted to the CCU during the study period .
Utilization was assessed using an ongoing CCU data collection
system during two 9-month time period s separated by a 9-month
transition period . During the first 9-month period , October 1, 1989
to June 30, 1990 (pre-ICA closure), the 7·bed medical-surgical CCU
operated independent of a separate 6-bed ICA that admitted both
medical and surgical patients not requiring invasive hemodynamic
monitoring or mechanical ventilatory support. The medical super-
vision of the ICA was independent of the CCU staff. Patients
requiring intensive nursing care (two nurses, one patient) but not
continuous hemodynamic monitoring or respiratory support were
admitted to the ICA facility based on medical and nursing needs .
A 9-month interval between pre- and post-ICA closure data
Closure of Intermediate Care Unit (Byrick , Mazer, CBskennette)
 Table I-Demographic and AdmiAion Datafor All CCU Table 2-UtiUmtion Datafor Alllbtienta During Each
Ibtienta During Each 9-Month Time fttriod* 9-Month Time fttriod*

Pre-ICA Post-ICA Pre-lCA Post ICA

Closure Closure Significance Closure Closure Significance

No . of patients 194 376 CCU length of stay, 8.5± 15.8 6.7±22.5 NS

Age, yr 58.2± 18.6 59.9± 16.7 NS days
Sex, MIF 108186 2281148 NS Hospital length of stay, 37.3±42.1 26.5±31.3 p<O.OOl
Hospital admission days
status OutcomeCCU
Nonemergency 65 156 p<O .03 (admissions)
177
~}
Emergency 129 220 NS Survival
NS
Postopemtive admissions 105 178 Death 40
Nonemergency 46 131 p<O.05 Outcome hospital
Emergency 59 47 (patients)
Survival 133
·Data reported as mean ± standard deviation. CCU =critical care NS
Death 61
=
unit; ICA intennediate care area.
TISS score
Admission 37.1±15.9 27.9±14.9 p<O.OOOI
collection allowed an adjustment period in admission/discharge
Discharge (modified 23.8 ±16.9 13.5±13.4 p<O.OOOI
policies after closure of the ICA and redistribution of hospital beds
TISS)
and staff. During the second 9-month data collection, April 1, 1991
APACHE II score 21.9±7.4 18.6±7.4 p<O.OOOI
to January 5 , 1992 (post-ICA closure), an expanded (9-bed) medical-
(admission)
surgical CCU operated without an ICA. During this post-ICA
closure period, all patients requiring more Intensive nursing and ·Data are reported as mean ± standard deviation. CCU =critical
medical care than available on the regu\ar wards were admitted to care unit; lCA =Intennediate care area; TISS =Therapeutic Inter-
theCCU . vention Scoring System.
During both data collection periods, CCU admission and dis-
charge were determined by the same critical care team. The total (dBase Iv, Borland, Scotts Valley, Calif) was used to develop the
number of hospital beds available was reduced from a daily average management program (Carebase) for entering, maintaining, and
of503 beds (range, 354 to 560) in the pre-ICA closure period to 467 analyzing coUected data. A tmined health records technician was
(range, 348 to 497) after ICA closure. The cause of the reduced responsible for reviewing each chart and entering data. The accuracy
number of beds and reorganization of critical care facilities was an of data for nondiagnosis-related fields, such as length of stay, have
institutional (opemting) deficit of $62 million . been verified on chart reabstraction to have match rates greater
than 95 percent. U
Data Collected
Infonnation collected on every admission to the medical-surgical Sta&tic6l Analyril
CCU included the following: age, sex , primary service referring Data are reported as mean ± standard deviation. Continuous
the patient, and type of hospital admission (emergency, nonemer- variables were compared using analysis of variance for parametric
gency). As well, the CCU length of stay, bospitallength of stay, and data and the Ko\mogorov-Smlrnov test for nonparametric data (eg,
survival were noted. length of stay). A statistical pacbge (SAS, Statistical Analysis
The severity of illness during the first 24 h In the CCU was System) was used for the analysis. Frequency data were examined
assessed using the APACHE II scoring system." This methodology using the 'It where appropriate. Differences were considered
scores, on a scale of 0 to 4, each of 12 physiologic variables significant when the p value was <0.05 .
commonly measured in critically ill patients. The APACHE II score
is composed of the weighted value of these physiologic variables RESULTS
(score increases based on the deviation from normal values during
the 24 h after admission) plus points for age and chronic health Table 1 summarizes demographic and admission
status. Speci6c consideration was given to standardization of values data for patients admitted during both 9-month data
for the Glasgow Coma Score, included as one of the 12 physiologic collection periods. The number of CCU admissions
variables. Since many postopemtive surgical patients were anesthe-
increased from 217 to 407 with closure of the ICA and
tizedand partially paralyzed on admission to the CCU, the Glasgow
Coma Score was recorded as nonnal if a postoperative patient was expansion of the CCU from 7 to 9 beds. The increased
awake and following commands within 24 h of admission. throughput in CCU was from 31 patients per CCU
The nursing wnrlcload and Interventions used during the first bed per 9 months to 45.2 patients per CCU bed per
24 h In the CCU were assessed using the Therapeutic Intervention 9 months. There was no significant change in the
Scoring System (I1SS) which weights critical care nursing interven-
proportion of CCU patients who were emergency
tions (one to four points per Intervention) based on complexity of
expertise required ." A " modified TISS" scored at the time of hospital admissions (1291194 vs 2201376); however, the
discharge from the CCU was also recorded as a "one-time" proportion of nonemergency admissions increased
measurement of nursing interventions ordered for each patient, not significantly (p<O.03). After ICA closure, the number
the cumulative 24-h score for admission TISS . The purpose of of emergency postoperative admissions remained sim-
recording the interventions (modified TISS) required for patient
care on leaving the CCU was to estimate the nursing care required
ilar (59 vs 47); however, an increased number of
after discharge. nonemergency postoperative surgical admissions were
Routine data collection by nursing staff was Integrated Into a noted compared with the 9-month period before ICA
CCU audit system.· A relational database management system closure (Table 1).

CHEST I 104 I 3 I SEPTEMBER. 1993 sn

 180
170
1lSO Pre-ICA Closure (n-217)
150
140
I
Post·ICA Closure (n-407)
130
1 120
E 110
~
'S 100

! :
70
eo
50
40
30
20
10
o
7 8 9 10 11 12 13 14 15 18 17 18 19 20 > 20 Days
Length Of Stay In Unit (days)
FIGURE 1. The number of admissions to the critical care unit (CCU) during two 9-month data collection
periods and the length of CCU stay ; the first (October I , 1989 to June 30, 1990) was before closure of a
six-bed intermediate care unit (pre-ICA closure) and the second (April I, 1991 to January 5, 1992) W'LS
after ICA closure and expansion of the CCU from 7 to 9 beds (post-ICA closure). ICA = intermediate care
area.

120 -

110 -

100 · ~ Pre-ICA Closure (0-217)

!0 90 ·
1m Post ·ICA Closu re (0-407)

1 80 ·
E
'a 70 -
e
'5 80 -
j
50 -

40 -

30 -

20

10 -

0
Dol 6-10 11-15 16-20 21·215 21-30 31-35 31-40 41~

APACHE II SCore
FIGURE 2. The number of admissions to the critical care unit (CCU) with varying severity of illness
(APACHE II score") during two 9-month data collection periods before (pre-ICA closure) and after (post-
ICA closure) closure of an intermediate care area (ICA).

878 Closure of Intermediate Care Un" (Byrick. Mazer, C8skennelte)

 A reduction in the mean length of hospital stay
(Table 2) was found after leA closure; however, no
difference in CCU length of stay was noted between
the two time periods. The range of ceu length of stay
varied from a minimum of 1 day to a maximum of 156
days before ICA closure and from 1 to 105 days after
ICA closure. These data are highly skewed to the left
(Fig 1). The median eeu length of stay was 3 days
pre-ICA closure and 2 days after ICA closure.
A significant decrease in the APACHE II score on
admission to the ecu was noted from 21.9±7.4 pre-
ICAclosure to 18.6± 7.4 after ICAclosure (p<O.OOOI).
The number of APACHE II points for chronic health
disability decreased from 4.52 ± 1.10 to 3.82 ± 1.47
(p<O.OOOl). The proportion of CCU admissions with
APACHE II scores greater than or equal to 15 did not
increase (187/217 vs 271/407) signtficantly after closure
of the ICA (Ftg 2). However, a larger number of ceu
admissions with APACHE II scores less than 15 were
admitted to the CCU after closure of the ICA (1361
407) than prior to closure (301217). The total number
of CCU days attributed to patients with APACHE II
scores less than 15 increased from 5.4 percent (100/
1850) to 12.7 percent (329/2702). No death occurred
in the 29 patients admitted prior to ICA closure with
APACHE II scores less than 15. After ICA closure,
there were only two deaths among patients admitted
to ceu with APACHE II scores less than 15 (one in
CCU and one after CCU discharge). Both patients
died suddenly; one unexpectedly 26 days after CCU
discharge of pulmonary embolus and the other of
irreversible central nervous system damage within 2
days of admission to the CCU.
The average TISS on admission to the CCU de -
creased (p<O .OOOl) after ICA closure (Table 2). In
addition, the TISS (modified) at the time of discharge
decreased from 23.5 ± 16.9 to 13.5 ± 13.4 (p<O.OOOI)
after ICA closure .
After ICA closure, the number of short-stay patients
(1- and 2-day CCU length of stay) increased signifi-
cantly from 92 to 243. The hospital mortality rate of
short-stay patients was 20.5 percent and 15.9 percent,
respectively, in each time period and the percentage
of total CCU days attributed to short-stay patients
increased from 6.64 percent to 11.59 percent after
ICA closure. Short-stay (1 to 2 days) patients had
admission TISS, after ICA closure, that was signifi-
cantly lower (22.8 ± 14.0) than for patients staying
longer than 2 days (34.7 ± 3.3) (p<O .OOO6). The mod -
ified TISS at the time of discharge was decreased
significantly in the short-stay group from 21.3 ± 17.2
to 13.0± 13.9 (p<O .OOO6) between the two time pe -
riods.
DISCUSSION
When hospital structure and organization change,
the utilization of key service components, such as
critical care, also changes. The high costs of critical
care and the limited acces s to these services necessi-
tates an organized approach to resource management
during periods of adjustment. Reports of CCU utili-
zation often study altered patterns of use when a
"step-down unit" or ICA is opened . Our data dem-
onstrated the extent of altered utilization of a multi-
disciplinary ceu when an ICA was closed and em-
phasized the need for a utilization management
system. The two key changes in utilization pattern
were the increased number of patients admitted with
a low severity of illness and an increased number of
patients discharged with significantly lower nursing
workload requirements. The magnitude of these two
changes in utilization pattern was large (Table 2), yet
commonly used measures, such as length of stay, did
not detect them. If physicians are to participate
effectively in resource management with nursing and
administrative colleagues, we must develop an organ -
ized approach to utilization analysis to understand the
factors that influence and measure use of resources.
This study demonstrates the value of the APACHE II
methodology as a validated tool for utilization assess-
ment and emphasizes the need to develop more
validated measures of nursing workload . Our experi-
ence also suggests that the beneficial effects reported
with creation of an ICA37 are reversed if the unit is
closed and reinforces the concept that the presence of
an ICA altered decision-making in a ceu . The
strategy of identifying "low-risk" groups requiring
fewer nursing resources and allocating these patients
to less intensively monitored or staffed locations was
inhihited by closing the ICA.
Critical care physicians and nurses have two poten-
tial options to manage access to critical care facilities.
The first strategy is to establish independent ICAs
that provide limited, well-defined intermediate levels
of care to decrease demand for critical care beds, The
alternate strategy would he the development offlexihle
staffing patterns and resource use within a multidis-
ciplinary CCU. For efficient use of personnel and
resources, this option would necessitate stratification
of critical care delivery according to patient need
within a diverse unit. Altering the supply of and
demand for critical cart' resources could theoretically
he accomplished hy either strategy, and either appears
preferable to formal explicit rationing. I
Cost considerations and increased throughput have
been the prime impetus encouraging alternate sites of
care for critically ill patients. Spivack" has estimated
that approximately $100,000 could he saved annually
per hospital if 10 percent of patients were diverted
from a 15-lw.d ceu with a 95 percent occupancy rate
to a noninvasive unit . He estimated that implementing
this strategy nationally in the United States could
CHEST I 104 13 I SEPTEMBER , 1993 879
result in a $500 million saving. We found that dismant-
ling the ICA resulted in 136 CCU patient admissions
with APACHE II scores less than 15 as compared with
30 in the pre-ICA closure period. This increase
represented approximately 25 percent of total CCU
admissions, but accounted for less than 10 percent of
CCU bed days in the 9 months after ICA closure.
We cannot comment on the cost-effectiveness to the
hospital of the decision to close the ICA because we
do not have accurate cost per patient data and because
the case-mix distribution clearly changed. The patient
population served by the ICA was admitted to either
the wards or to the CCU in the post-ICA closure
period. After ICA closure, we found an increased
proportion of CCU admissions and patient days that
were accounted for by patients requiring less nursing
care with lower APACHE II scores. The potential for
inefficient use of critical care personnel and resources
increased when the ICA with its "graded" level of care
was withdrawn without a change in CCU management.
Since personnel costs account for approximately 80
percent of critical care expenditures, the need for a
nursing workload management system during periods
of changing utilization is particularly important. In the
absence of an ICA, increased cost-effectiveness might
be gained by providing graded levels of care within a
CCU to patients with possible acute myocardial in-
farction.v' respiratory failure," and medical surgical
patients," Henning et al l 3 proposed using severity of
illness measures (APACHE II system) to identify
patients eligible for intermediate levels of care. How-
ever, this index alone may not be appropriate for all
groups and must be investigated further,14 because
nursing workload and level of care do not always
correlate directly with APACHE II scores," Thus, a
utilization analysis process that includes nursing work-
load assessment is most important when the hetero-
geneity of severity of illness increases within a CCU.
A successful ICA strategy should emphasize that
unit managers focus on discharge policies and priori-
ties, and design ICA units to meet specific hospital
needs. Our data suggest that discharge criteria (eg,
modified 11SS) are as important as admission criteria
for efficient utilization. Physicians can alter priorities
for admission and discharge when confronted with a
resource (bed or nursing) shortage.w'" Strauss et al l7
have shown that the relationship between bed availa-
bility on a given day and the severity of illness of
patients admitted and discharged was inversely pro-
portional. Factors other than bed availability that can
influence admission and discharge criteria are prog-
nostic uncertainty, patient age,18 expected social ca-
pacity;" quality of life,oo family preferences, and the
organization of critical care delivery," Kalb and Miller!
suggested that severity of illness and medical suitabil-
ity rather than "marginal benefit" should be the
880
overriding determinant in allocating access to critical
care.
Admission and discharge decision-making regarding
"low-risk" monitored admissions will depend on what
alternatives are available outside the CCU. Closure of
the ICA reduced flexibility in discharging patients and
thus, the capacity to adjust discharge decision-making
was lost. This lost flexibility resulted in no change in
mean CCU length of stay, in spite of the increased
number of "low-risk" admissions with low APACHE
II scores; these patients stayed only 1 or 2 days.
Medical suitability remains the basis for CCU admis-
sion and discharge decision-making. Little attention
has been paid to establishing priorities for discharge,
although physicians do this daily.
In this study, important changes in CCU utilization
occurred without any significant differences in overall
CCU length of stay. This happened because the effect
of an increased number of short-stay patients with low
APACHE and 11SS scores was offset by the necessity
of keeping "sicker" patients longer in the CCU because
of the lack of stepdown facilities to discharge them to .
Similarly, the reduction in calculated mortality rate
for patients staying in the CCU only 1 or 2 days
probably does not reflect a change in the quality of
care provided because the severity of illness and
preadmission chronic health disability decreased .
Thus, the CCU length of stay and mortality rates,
taken in isolation, are not sufficient measures of CCU
utilization, especially during times of administrative
change.P
In conclusion, we found that the structure and
availability of non-CCU facilities, such as the ICA, to
a significant extent determined the utilization of a
critical care facility. Our data emphasize the need to
take a "system" approach to utilization analysis in
critical care. Utilization analysis must therefore con-
sider both the need for CCU and the facilities available
in the CCU, as well as in the hospital and the health
care system. These facilities vary with time and place
and must be defined in order to properly interpret
CCU utilization data. The need for a continuous audit
ofCCU utilization is most marked when organizational
strategies are changing. The result of our analysis was
the reestablishment of a unit (ICA) to provide specified
monitoring (ECG and pulse oximetry) to "low-risk"
monitored patients in a less intensively staffed area.
As well, the need for a CCU audit became the focus
of a utilization management system with an emphasis
on nursing workload assessment and severity of illness.
It is only by taking advantage of these "natural
experiments" which occur in all organizations that we
will be able to study factors that determine the proper
allocation and utilization of critical care resources.
ACKNOWLEDGMENTS: The authors wish to express appreciation
to Ms. Cathy Mechetuk and David Leung of the Medical Records
CIosuI8 oIlntermedlate Care Unll (ByrIck. M8Z~ ClJskenneltfJ)
Department for assistance with data entry, Mr. Colin Kay for
statistical analysis, and Ms. Kerry McClenaghan for preparation of
the manuscript.
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