Robert Stretch1, Nicolás Della Penna2, Leo Anthony Celi3, Bruce E Landon4,5. 1. Department of Medicine, Beth Israel Deaconess Medical Center, Boston, MA. 2. Research School of Computer Science, Australian National University, Canberra, ACT, Australia. 3. Laboratory for Computational Physiology, Massachusetts Institute of Technology, Cambridge, MA. 4. Department of Health Care Policy, Harvard Medical School, Boston, MA. 5. Division of General Medicine and Primary Care, Department of Medicine, Beth Israel Deaconess Medical Center, Boston, MA.
Abstract
OBJECTIVES: Hospitals use a variety of strategies to maximize the availability of limited ICU beds. Boarding, which involves assigning patients to an open bed in a different subspecialty ICU, is one such practice employed when ICU occupancy levels are high, and beds in a particular unit are unavailable. Boarding disrupts the normal geographic colocation of patients and care teams, exposing patients to nursing staff with different training and expertise to those caring for nonboarders. We analyzed whether medical ICU patients boarding in alternative specialty ICUs are at increased risk of mortality. DESIGN: Retrospective cohort study using an instrumental variable analysis to control for unmeasured confounding. A semiparametric bivariate probit estimation strategy was employed for the instrumental model. Propensity score matching and standard logistic regression (generalized linear modeling) were used as robustness checks. SETTING: The medical ICU of a tertiary care nonprofit hospital in the United States between 2002 and 2012. PATIENTS: All medical ICU admissions during the specified time period. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: The study population consisted of 8,429 patients of whom 1,871 were boarders. The instrumental variable model demonstrated a relative risk of 1.18 (95% CI, 1.01-1.38) for ICU stay mortality for boarders. The relative risk of in-hospital mortality among boarders was 1.22 (95% CI, 1.00-1.49). GLM and propensity score matching without use of the instrument yielded similar estimates. Instrumental variable estimates are for marginal patients, whereas generalized linear modeling and propensity score matching yield population average effects. CONCLUSIONS: Mortality increased with boarding of critically ill patients. Further research is needed to identify safer practices for managing patients during periods of high ICU occupancy.
OBJECTIVES: Hospitals use a variety of strategies to maximize the availability of limited ICU beds. Boarding, which involves assigning patients to an open bed in a different subspecialty ICU, is one such practice employed when ICU occupancy levels are high, and beds in a particular unit are unavailable. Boarding disrupts the normal geographic colocation of patients and care teams, exposing patients to nursing staff with different training and expertise to those caring for nonboarders. We analyzed whether medical ICU patients boarding in alternative specialty ICUs are at increased risk of mortality. DESIGN: Retrospective cohort study using an instrumental variable analysis to control for unmeasured confounding. A semiparametric bivariate probit estimation strategy was employed for the instrumental model. Propensity score matching and standard logistic regression (generalized linear modeling) were used as robustness checks. SETTING: The medical ICU of a tertiary care nonprofit hospital in the United States between 2002 and 2012. PATIENTS: All medical ICU admissions during the specified time period. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: The study population consisted of 8,429 patients of whom 1,871 were boarders. The instrumental variable model demonstrated a relative risk of 1.18 (95% CI, 1.01-1.38) for ICU stay mortality for boarders. The relative risk of in-hospital mortality among boarders was 1.22 (95% CI, 1.00-1.49). GLM and propensity score matching without use of the instrument yielded similar estimates. Instrumental variable estimates are for marginal patients, whereas generalized linear modeling and propensity score matching yield population average effects. CONCLUSIONS: Mortality increased with boarding of critically illpatients. Further research is needed to identify safer practices for managing patients during periods of high ICU occupancy.
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