See Article, p 1337
Until recently, conventional wisdom held that the United States had more intensive care unit (ICU) beds than it really needed. With higher supply of ICU beds per capita than other high-income countries, it appeared that less sick patients were occupying available beds, a condition known as demand elasticity.1 Put differently, a surplus of critical care beds appears to result in increased use or supply-induced demand. Studies in support of this idea showed that, when ICU demand increased or when ICU supply precipitously decreased, less sick patients were moved out or did not gain admission to the ICU without substantial effect on outcomes.2–4 Based on these data, the United States could eliminate ICU beds without impacting the quality of patient care.
This view may have changed in the setting of the coronavirus disease 2019 (COVID-19) pandemic. With surges in critically ill patients and many hospitals overwhelmed with demand for ICUs, it may appear that we do not have enough ICU beds. Support for this perspective comes from the horrific experiences of New York City and the Lombardy region in Italy, which yielded images only previously imaginable in times of war. As a result, US states have scrambled to increase the effective ICU supply through a wide variety of means, including, among other strategies, ordering the suspension of elective surgeries.
Against this backdrop, Poeran et al5 retrospectively reviewed 5 years of New York State data on ICU utilization and mechanical ventilation to determine how many free beds could be created by cancelling elective surgery. They found that from 2011 to 2015, 13.4% of total ICU admissions were attributable to elective surgery. Of patients admitted to ICUs requiring mechanical ventilation, only 6.4% were attributable to elective surgery. Notwithstanding methodologic limitations of this retrospective study of administrative data and combining together with other scholarship,6 these findings show that there may not be a lot of opportunity to add ICU bed capacity in a pandemic surge by cancelling elective cases. Poeran et al5 demonstrated that the majority of ICU admissions during their study period resulted from medical cases followed by emergent, urgent, and trauma surgery.
These results beg 2 important questions. The first is whether cancelling elective surgical cases is sound health policy in a pandemic. The answer to this question is more complex than a single study can answer. Although Poeran et al5 estimate that the number of “new ICU” beds created is relatively small on a percentage basis, the absolute number of ICU admissions attributable to elective surgery identified by Poeran et al5(pp165,365) is still meaningful. And beyond creating ICU capacity, there are other good reasons to cancel elective cases in a pandemic. These might include freeing personnel to assist with other surge activities, decreasing pressure on limited personal protective equipment, and protecting the well-being of frontline staff, some of whom would potentially be infected or risk infecting family members. Additionally, ICU bed availability represents only one aspect of operations, and their scarcity becomes more disruptive to patient flow throughout the hospital as fewer beds are available. Finally, in our highly complex health care systems, cancelling elective surgery is one of the few things that an individual hospital can do.
Yet any of these benefits from blanket cancellations must be balanced against the documented risks associated with postponing elective procedures. The definition of elective is, of course, in the eye of the beholder. Many “elective” cases exist in a “grey zone” between truly elective and urgent. Some may lead to earlier diagnoses of treatable illnesses. Others might substantially reduce care requirements by mobilizing otherwise infirm patients or provide meaningful relief of suffering. The adverse impacts on individuals were substantial. It is difficult to overcome the anxiety of a patient with a new diagnosis of a malignancy who can neither be adequately staged nor treated. Or a patient with inflammatory bowel disease who has failed medical management having to endure continued suffering rather than receive a definitive operation. Even among “elective” cases, some are more elective than others and have different resource requirements.
Elective surgical and other interventional procedures are also an important source of hospital revenue. Although it may seem insensitive to think of hospital finances during a pandemic, severe financial losses can immediately translate to losses of both jobs for health care workers and access to health care if hospitals close. Fortunately, we now know more about this particular pandemic than we did when it started, and health care systems have had time to stockpile personal protective equipment and other materials, allowing for more thoughtful approaches to capacity management than blanket cancellations of all elective procedures.
The second question is whether we need more ICU beds in the United States. While the images of patients dying in hospital corridors were undoubtedly disturbing, our answer is a resolute “no.” Several points inform this response. First, from what we know today, more ICU beds would have only helped one area, metropolitan New York City, and then only for a brief period of time. Second, having more ICU beds “at the ready” everywhere in the United States would have been unsustainably costly. ICU beds are expensive. Most of their costs are fixed,7 and when they go unfilled or inappropriately used, those costs are handed on to our society. Third, while ICU beds were frighteningly scarce in New York, they were plentiful elsewhere. More effective regional care coordination could have allowed sick patients in New York to move to other regions. Such efforts were successfully undertaken in France, decreasing the demand on ICU beds in hard hit parts of the country.8
It is true that moving critically ill patients across state lines to better match demand would be politically challenging. It also may well have been met with resistance from families. Nevertheless, the financial costs would be tiny compared to an expansion of ICU bed supply and attendant efforts, such as deploying naval hospital ships. Importantly, creating more capacity in hospitals with insufficient ICU beds may have permitted urgent non-COVID-19 patients whose care was delayed to have been treated faster.
The United States has 25 ICU beds per 100,000 people, when compared with 5 per 100,000 in the United Kingdom.9 In the United Kingdom, ICU patients are at higher risk of death than in the United States, whereas more people in the United States die in the ICU than in the United Kingdom.10 Together these data suggest that fewer patients in the United States are likely to benefit from ICU care than in the United Kingdom. When the pandemic is over, these numbers are not likely to change. If anything, we need fewer ICU beds in the United States. At the same time, policies that enable more facile transfer of patients across regions could prevent the need for some of these difficult discussions during the next pandemic. In the meantime, we are left with piecemeal approaches. Reducing the volume of elective surgery during a surge is one.
Name: Michael Nurok, MBChB, PhD.
Contribution: This author helped write and edit the manuscript.
Conflicts of Interest: M. Nurok reports receiving stock options for his role as an adviser to Avant-garde Health.
Name: Jeremy M Kahn, MD, MS.
Contribution: This author helped write and edit the manuscript.
Conflicts of Interest: None.
This manuscript was handled by: Avery Tung, MD, FCCM.
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