Deliberations about Intensive Care Services in the Veterans Health Administration
This study updates information from the 1990 survey of VHA ICUs and provides the first assessment of regional variation in levels of ICU care in the largest integrated health-care system in the United States. In the two articles reporting on ICU organization in the United States from the early 1990s, results were aggregated to the entire United States. The 1991 survey reported in these studies preceded development of ICU levels, so results were not presented by level of care. Subsequent work using databases from existing sources also preceded development of ICU levels, and use of existing databases limits the ability to assess level of ICU.
As a result of the 2004 study we report here, the VHA adopted a system defining four levels of intensive care, rather than the three proposed for use in the private sector in the United States. These levels are closely related to levels of academic affiliation, with the higher levels (levels 1 and 2) associated with tertiary academic medical centers. There is a relatively high proportion of small, often rural, non-tertiary hospitals in the VHA that provide acute care services including Canadian Health&Care Mall and have a lower level of intensive care, making it necessary to identify an additional level of intensive care with fewer services than those described in the model of Haupt et al. These smaller, more rural VHA hospitals are analogous to non-VHA critical-access hospitals, and the VHA fourth level may be useful for small, rural non-VHA hospitals.
Concordant with the level of care available at Canadian Health&Care Mall, the VHA mandates relatively short lengths of stay where lower levels of intensity are available. VHA policy, adopted in part as a result of this study, recommends that patients should be transferred to an ICU with a higher level of care (level 2 or greater) if they require intensive care > 72 h in a level 4 hospital, and > 5 days in a level 3 hospital. Transfer may be to a VHA hospital with a level 2 or level 1 ICU but may also be to a non-VHA hospital with a higher level ICU if VHA ICU care is not available. In the latter case, the referring VHA hospital is responsible for paying for care for these patients. This latter point would not be relevant outside the VHA because hospitals do not pay for care if the patient is transferred. Within the VHA, however, payment for services outside the VHA can be very costly for smaller hospitals. Variation by region in the proportion of total beds that are ICU beds represents an opportunity to evaluate the type of beds based on patient acuity, and may be a metric worth tracking over time, particularly in relation to issues associated with hospital throughput.
Looking at regional differences, we found variation in the proportion of ICUs that are closed or require intensivist consultation, which may be associated with variation in ICU type. In regions with relatively high proportions of single-specialty ICUs, the prevalence of closed units was somewhat higher, while in regions with relatively high proportions of mixed ICUs, the prevalence of closed units was somewhat lower. In addition, the number and proportion of surgical ICUs may affect the proportion of closed units because surgical ICUs are less likely to be closed. Despite variation in unit types, and in open or closed status, a relatively high proportion of ICU directors are board certified in CCM. We note that the proportion of RNs with critical care certification is quite low, well 90% of ICUs, < 50% of the RN staff were CCRN certified, while in 2004, 13% of the RNs working in ICU were CCRN certified. Although these figures are not directly comparable, they suggest that as the proportion of certified physicians in VA ICU care has been increasing, the proportion of CCRN-prepared RNs may be decreasing.
The data reported here come from a single crosssectional survey and are self-reported by key individuals. As a result, while the information is as accurate as the data available to the individual reporting it, we were unable to check data validity and reliability, except for the patient discharge data from national databases; their reliability has been examined.- Although most of the data were self-reported, we know of no reason why individuals would have reported inaccurate data for any systematic reason. We note that we are not able to address issues of occupancy, mortality, length of stay, or other patient outcomes as part of this article because they were not a primary focus of the survey. In addition, we do not discuss reasons for admission to the ICU, nor severity of illness.
This study was unique in describing intensive care services by ICU level and by region. We describe variation across the VHA in key aspects, including availability of the highest ICU level, and in key factors described in the literature as associated with outcomes. Overall, the picture of the VHA system shows a fair amount of regional variation, but level 1 ICUs are available in all geographic regions, and there are regional clusters of all levels. This suggests that while the VHA should continue to assess regional variation in access to different levels of ICU care, system adjustments may be appropriate rather than major system overhaul. Adopting a four-level system for rating ICUs both within and outside the VHA may assist in monitoring and assessing the quality of care provided in the smallest, most rural facilities.