Roanoke Times
Copyright (c) 1995, Landmark Communications, Inc.
DATE: SATURDAY, March 3, 1990 TAG: 9003052207
SECTION: VIRGINIA PAGE: A5 EDITION: METRO
SOURCE: CHARLES HITE MEDICAL WRITER
DATELINE: LENGTH: Medium
Consider the case of Mr. J, a 43-year-old man who needed a kidney transplant.
The day before his surgery, Mr. J's doctor requested that his patient be sent to UVa's surgical intensive care unit to recover from the transplant procedure.
The request was denied. Mr. J was sent to a general ward. About 12 hours later, Mr. J had trouble with secretions blocking his airway. Two hours later, he had to be put on a breathing machine. He was transferred to the surgical intensive care unit in critical condition.
On the morning that Mr. J was denied admission to the SICU, three beds were open on other intensive care units in the hospital. That same morning, four patients from the Thoracic-Cardiovascular (TCV) service were admitted to the SICU. One patient already on the unit had been there for five months with chronic respiratory failure.
Mr. J was one of 308 patients seeking admission to the SICU during a three-month period in the spring and summer of 1988. A study of the patients denied admission concludes that "medical provincialism" may override the needs of patients in allocating beds on critical care units.
Decisions to go ahead with elective surgery during a period when beds were scarce on the SICU were "motivated by monetary as well as political considerations," the study says. "Rationing practices . . . were often subjective and perhaps inequitable."
The study seems to back up a common belief of many intensive care nurses: The heart and chest surgeons have more clout in getting beds for their patients because heart and chest surgery is a big moneymaker for the hospital.
The study notes that only 1.6 percent of the patients from TCV surgery were denied admission, while 10.5 percent of general surgical patients were denied. But the patients from general surgery who were denied were sicker than those denied from TCV surgery.
"Political clout within the institution led the cardiothoracic surgeons into this favored position in the SICU," the study says. "They were the major users and generated the largest proportion of hospital income for the unit and other areas as well."
Another surprising result of the study: As fewer beds became available on the SICU, the patients admitted were not as ill. This finding was completely opposite of another well-known study that showed the severity of illness of patients increased as beds became scarce.
"Our data shows that admitting patterns did not change and no attempts were made to limit admissions to more severely ill patients during times of the greatest shortage of ICU beds," the study says.
The study also found that surgeons did not use other intensive care units in the hospital when no beds were available in SICU.
"Other units were capable of caring for certain critically ill surgical patients but it was a matter of personal preference on the part of the surgical attendings not to use this option," the report says.
Part of the reason, the study suggests, is that surgeons didn't want to lose control of their patients by sending them to another ICU. By transferring a patient to a non-surgical ICU, decisions about a patient's care rests with the staff on that unit, not the surgeon.
"It would appear that the surgeons would rather retain control of their patient's care on a general ward with a surgical ward nurse not trained in critical care than to admit to non-SICU critical care units," the study says.
Since the study was conducted, the surgical intensive care unit has been broken into three separate critical care areas. TCV surgeons now have their own ICU, as do neurosurgeons.
But rationing problems continue.
Nurses on the Medical Intensive Care Unit complain that surgical ICUs "dump" patients who are doing poorly and can't be managed well. Yet when medical ICU patients develop surgical problems, the other units seem reluctant to take them.
"It's all take; there's no give on their part," says Tamara Perdue, a nurse on the MICU.
Last winter, a group of nurses on the surgical intensive care unit became so upset with the care of a liver transplant patient that they asked to meet with the head of the hospital's ethics consult team.
One of their major concerns was that the patient, who had received three transplants, clearly was dying and tying up resources and space that should be made available to other patients. They complained that the transplant patient was being treated differently because the hospital's liver transplant program was just getting off the ground.
Memo: Life and Death in Intensive Care