Improving the quality and utilization of critical care.

Critical care units have proliferated over the past three decades and the cost of care in these units has increased dramatically during that period. These units have flourished despite a surprising lack of adequate data to support their overall efficacy, and indeed a number of studies suggest that many patients admitted to these units are either too ill or too healthy to benefit. Dr Luce reviews recent changes in the organization and delivery of critical care and argues that the utilization and quality of critical care units can be improved through a combination of strategies. He advocates two strategies to decrease the demand for, or increase the supply of, critical care beds: more efficient use of intermediate care units and the development of clear institutional guidelines regarding the termination of treatment. In addition, although nominally eschewing the use of "formal" rationing policies, he advocates the development of admission and discharge policies to guide physicians during periods of low bed availability. Finally, he advocates greater leadership roles for professional critical care unit directors. This final suggestion has great merit but, as Dr Luce recognizes, a heightened role for critical care unit directors raises ethical and legal issues about the autonomy of both patients and physicians that need to be explored thoroughly.