Adult Sepsis Guidelines
Children's Sepsis Guidelines
Adult ICU Liberation Guidelines
PANDEM Guidelines for Children and Infants
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The Critical Care Statistics guide provides statistics on many of the current issues in critical care in the United States. It is intended to be used as a reference in efforts such as advocacy, public relations, and general education.
Critical Care Statistics
The Society of Critical Care Medicine (SCCM) represents over 16,000 highly trained professionals in more than 100 countries who provide care in specialized units and work toward the best possible outcomes for all critically ill and injured patients. SCCM maintains that multidisciplinary care teams led by intensivists (physicians trained and credentialed in critical care medicine [CCM]) are essential to critical care delivery, improve conditions for healthcare providers, and boost hospitals’ financial performance. This guide provides statistics on many of the current issues in critical care in the United States. It is intended to be used as a reference in efforts such as advocacy, public relations, and general education.
Costs of Critical Care
Between 2000 and 2010, annual CCM costs increased 92%, from $56.6 billion to $108 billion. The 2010 costs represent 13.2% of hospital costs, 4.1% of national health expenditures, and 0.72% of gross domestic product. Intensive care unit (ICU) costs per day in 2010 were estimated to be $4300 per day, a 61% increase since the 2000 cost per day of $2669.
United States Resource Availability for COVID-19
This new report from SCCM updates key statistics not previously published and puts this pandemic in historical perspective, discussing key resource availability. The report provides data on:
Possible Cost Savings
Cost savings of up to $1 billion per quality-adjusted life-year gained can be attained with critical care management of severe sepsis, acute respiratory failure, and general critical care interventions. The use of 24-hour intensivist staffing is purported to have several advantages, including decreased costs, mortality, complications, hospital length of stay (LOS), improved physician satisfaction, and decreased burnout. However, the majority of studies regarding the benefits of 24/7 intensivist staffing were conducted primarily at tertiary or academic centers that have high patient acuity and volume. Up to $13 million in annual hospital cost savings can be realized when care is delivered by an intensivist-directed multidisciplinary team. The impact of this type of care is demonstrated by the example of a community hospital that achieved 105% return on investment by implementing mandatory intensivist consultation and admission standards, thereby reducing ICU LOS, ventilator-associated events, and central venous access device infection rates.
Hospitals without on-site intensivists may benefit from telemedicine or tele-ICU services, in which sophisticated electronic systems connect ICU patient data to intensivists at remote locations. The intensivists provide real-time monitoring, diagnostic, and intervention services and work with bedside staff. Telemedicine intensivists also interact with patients and their family members. In selected settings, tele-ICU care has demonstrated shorter ICU LOS and lower ICU mortality, which may translate into lower hospital costs and better use of resources. A systematic review and meta-analysis of 19 ICU telemedicine studies concluded that tele-ICU programs were associated with reductions in ICU and hospital mortality and ICU LOS but not in hospital LOS and were costly to implement. A recent study from the Emory Critical Care Center showed that implementation of an advanced practice provider (APP) residency program and tele-ICU staffed with critical care nurses and consultant intensivists resulted in a $4.6 million cost savings.
Critical Care Patients
More than 5 million patients are admitted annually to U.S. ICUs for intensive or invasive monitoring; support of airway, breathing, or circulation; stabilization of acute or life-threatening medical problems; comprehensive management of injury and/or illness; and maximization of comfort for dying patients. ICU patients are a heterogeneous population, but all share the need for frequent assessment and a greater need for technological support than patients admitted to non-ICU beds.
Adult: Cardiac, respiratory, and neurologic conditions are common in adult ICU patients. The five primary ICU admission diagnoses for adults are respiratory insufficiency/failure with ventilator support, acute myocardial infarction, intracranial hemorrhage or cerebral infarction, percutaneous cardiovascular procedures, and septicemia or severe sepsis without mechanical ventilation. Other conditions and procedures involving high ICU use are poisoning and toxic effects of drugs, pulmonary edema and respiratory failure, heart failure and shock, cardiac arrhythmia and conduction disorders, renal failure with major complication or comorbidity, gastrointestinal hemorrhage with complication or comorbidity, and diabetes with complication or comorbidity. The most common technological support is mechanical ventilation, required by 20%-40% of U.S. ICU admissions.
Pediatrics: Patients admitted to the pediatric ICU (PICU) may have either acute illness or acute exacerbations in the context of complex chronic conditions. Respiratory illnesses are the most common diagnoses. The median age of children admitted to the PICU ranges from less than 1 year to 1.9 years. The most common indications for admission to the PICU include respiratory disease, cardiac disease, and neurologic disorders. Children with developmental delay can make up to as many as 38% of PICU admissions. The LOS is greater than 7 days in more than 35%-40% of admitted patients, and more than 40% of PICU admissions require mechanical ventilation. Severe sepsis and septic shock are also common in PICUs, with a prevalence of more than 8% worldwide and a mortality rate of more than 24%.
Neonatal patients admitted to the neonatal ICU (NICU) are born either preterm or at term with serious medical or surgical conditions. While the majority of very-low-birth-weight (< 1500 g) newborns are cared for in NICUs, greater than half of NICU admissions were born at term and with normal birth weights. Outcomes are improved for high-risk newborns, especially preterm infants, born in facilities with a NICU. Mortality rates in NICUs range from 4% to 46% in developed countries and 0.2% to 64.4% in developing countries. The American Academy of Pediatrics (AAP) defines a NICU as a facility able to provide newborn care with sustained life support, a full range of respiratory support, access to pediatric medical and surgical specialties, pediatric anesthesiologists, and pediatric ophthalmologists. The AAP defines the NICU in terms of four levels of care with increasing capabilities as the levels increase (level I: well-baby nursery, level 2: special-care nursery, levels III and IV: full ICU care).
Intensive Care Unit Facilities
Data on U.S. ICU facilities are available from two national hospital databases: the American Hospital Association (AHA) Hospital Statistics system and the U.S. Centers for Medicare and Medicaid Services Healthcare Cost Report Information System (HCRIS). AHA offers data on the number of ICU beds and units for adult (medical-surgical, cardiac, and other) and child (pediatric and neonatal) units as well as similar data for burn units and observation, step-down, or progressive beds. AHA offers no data on bed utilization. HCRIS offers bed and use data on adult (intensive care, coronary care, surgical/trauma, burn, psychiatric/detoxification) and child (pediatric and neonatal) beds (but not units). HCRIS data include U.S. government-based Medicare and Medicaid use. HCRIS has no data on observation, step-down, or progressive beds.
AHA data: According to the AHA 2015 annual survey, the United States had 4862 acute care registered hospitals; 2814 of these had at least 10 acute care beds and at least 1 ICU bed. These hospitals had a total of 540,668 staffed beds and 94,837 ICU beds (14.3% ICU beds/total beds) in 5229 ICUs. There were 46,490 medical-surgical beds in 2644 units, 14,731 cardiac beds in 976 units, 6588 other beds in 379 units, 4698 pediatric beds in 307 units, and 22,330 neonatal beds in 920 units. The median number of beds in medical-surgical, cardiac, and other units was 12, with 10 beds in pediatrics and 18 in neonatal. Fifty-two percent of hospitals had 1 unit, 24% had 2 units, and 24% had 3 or more units.
HCRIS data: In 2010 there were 2977 acute care hospitals with ICU beds. In these, there were 641,395 total acute care beds with 103,900 ICU beds (16.2% ICU beds/total beds). From 2000 to 2010, the number of critical care beds in the United States increased by 17.8%, from 88,235 to 103,900. However, the majority of the growth in critical care bed supply is occurring in a small number of U.S. regions that tend to have large populations, fewer baseline ICUs per 100,000 capita, higher baseline ICU occupancy, and increased market competition. Additionally, between 2000 and 2010, the greatest percentage increases were in neonatal beds (29%), followed by adult beds (26%); there were minimal changes in pediatric beds (2.7%). Of the 103,900 ICU beds in 2010, 83,417 (80.3%) were adult, 1917 (1.8%) were pediatric, and 18,567 (17.9%) were neonatal. In total, there were 33.6 beds per 100,000 population, 35.5 beds per 100,000 adult beds (age > 18 years), 2.7 beds/100,000 pediatric beds (age 1-17 years), and 470 beds/100,000 neonatal beds (age < 1 year).
ICU days: HCRIS analysis showed that there were 150.9 million hospital days, including 25 million ICU days in 2010 (16.5% ICU days/total days). Medicare accounted for 7.9 million ICU days (31.4%) and Medicaid 4.3 million ICU days (17.2%).
Occupancy: Occupancy rates were calculated from HCRIS (days/possible days) data. In 2010, hospital and ICU occupancy rates were 64.6% and 68%, respectively. Occupancy rates vary by hospital size, with higher occupancy rates associated with larger hospitals.
Length of Stay
ICU LOS has been estimated at 3.8 days in the United States. However, it varies depending on patient and ICU attributes.
Morbidity and Mortality
Despite an increasing age and severity of illness in ICU patients, there was a 35% relative decrease in mortality for ICU admissions from 1988 to 2012. The leading causes of death in the ICU are multiorgan failure, cardiovascular failure, and sepsis. Sepsis affects more than 1.7 million people in the United States and is the leading cause of death in U.S. hospitals, accounting for 270,000 deaths annually. It is also the major cause of readmissions to the hospital within 30 days, costing more than $2 billion annually. Of patients who are diagnosed with sepsis, up to 51% develop acute renal failure, and up to 20% have acute respiratory failure requiring mechanical ventilatory support. More than 75,000 children develop sepsis each year and 6800 of these children die.
Overall, mortality rates in patients admitted to adult ICUs average 10% to 29%, depending on age, comorbidities, and illness severity. The mortality rate for patients who have been admitted to the ICU is greater for the next 10 years after they leave the ICU compared with patients of the same age who have never been admitted to the ICU. The overall mortality rate for pediatric ICU patients ranges from 2% to 6%.
Staffing and Salaries
The multidisciplinary ICU team may consist of critical care nurses, APPs (nurse practitioners and physician assistants), intensivists, hospitalists, pharmacists, respiratory therapists, nutritionists, social workers, and other professionals. Challenges exist in defining these groups and obtaining data. For example, an intensivist can be defined as a physician formally trained in critical care, with or without CCM board certification, and working in the ICU with variable time commitments. However, a hospitalist, without formal CCM training, may be privileged to deliver CCM care. ICU nurses are easily identified; however, the American Association of Critical-Care Nurses (AACN) does not keep a global database. Similar problems exist in determining total numbers of respiratory therapists and pharmacists and those who work primarily in the ICU. Salaries are similarly difficult to determine because they vary greatly by experience, location, type of hospital and work model, and of course public reporting.
CCM nurses: According to Connie Barden, Chief Clinical Officer of the AACN, the critical care nurse universe is approximately 512,000 (figure derived from National Council of State Boards of Nursing 2017 RN Practice Analysis, State of Nursing 2016 Whitepaper [nursing.org], and the 2015 National Nursing Workforce Survey [J Nurs Regul. 2016;7:S1-S90]). Salaries for critical care nurses range from $66,316 to $79,962, but these salaries vary widely depending on education, certifications, additional skills, and number of years spent in the profession.
APPs: Estimates suggest that more than 29,700 acute care nurse practitioners and 1500 physician assistants practice critical care in the United States. Mean salaries were estimated at $122,432 for acute care nurse practitioners, and $122,957 for physician assistants.
Intensivists: AHA data for 2015 suggested that there were approximately 29,000 privileged intensivists in the United States, accounting for 20,000 full-time-equivalent intensivists. American Medical Group Association physician compensation data shows that median compensation for intensivists in 2017 was $400,000; Medscape Intensivist Compensation Report 2018 lists this figure as $354,000.
Respiratory therapists: The most recent (2016) data from the U.S. Bureau of Labor Statistics estimates a national total of 130,200 respiratory therapists. Their median salary is $59,710.
ICU pharmacists: In 2012, a task force of critical care pharmacists sponsored by the American College of Clinical Pharmacy, American Pharmacists Association, and American Society of Health-System Pharmacists (ASHP) estimated that there were 6000-7000 practicing critical care pharmacists in the United States with an estimated mean annual salary of $125,000. A 2011 ASHP national survey showed that pharmacists were assigned to critical care in 68.8% of U.S. hospitals.
Increasing ICU bed numbers over the past four decades seem to reflect an increase in the demand for critical care services. Several factors appear to have driven the increase in demand. These include an improved life expectancy, a larger aging population, and advances in medical therapeutics.
Concomitantly, the Committee on Manpower for Pulmonary and Critical Care Societies (COMPACCS) published a well-researched statistical projection study in 2000 that suggested a looming intensivist shortage. More recent government reports have shown equivocal information. There are two schools of thought on whether an intensivist shortage actually exists. The first suggests that ICU beds, while increasing in number, are not always used properly. Thus, many patients admitted to ICUs either cannot benefit from ICU care because they are too healthy or are at the end of life. Thus, there are too many ICU beds and possibly too many intensivists. Additionally, not all ICU patients require intensivist-level care throughout their entire ICU stay. The second school of thought suggests that there is an ongoing and increasing intensivist shortage that is failing to keep up with the realities of ICU admissions and the stretching of ICU providers to deliver care throughout the entire hospital (ie, staffing 24/7 rapid response teams), participating in 24/7 in-house ICU coverage, providing teaching and training for all members of the ICU staff, and participating in ICU administrative oversight and quality and safety and research activities.
A study analyzing the 2814 acute care hospitals in the United States with ICU beds in the 2015 AHA database found that hospitals were evenly divided as to the presence of intensivists; 1469 (52%) had intensivists and 1345 (48%) did not. Hospitals with intensivists were more likely to be located in metropolitan areas and had nearly thrice the number of aggregate hospital beds, 3.6 times the number of ICU beds, and almost twice as many ICUs compared with hospitals without intensivists. However, the hospitals with intensivist coverage had approximately 75% of the ICU beds, suggesting that the intensivist shortage may not be as problematic as perceived.
Another problem in understanding the scope of ICU coverage and the adequacy of the intensivist workforce is that it is difficult to ascertain the scope of ICU telemedicine programs. It is possible that hospitals without intensivists who are privileged and administering care on site may have telemedicine contracts.
The training pipeline: Understanding the CCM fellowship training landscape is challenging. Over the past decade (2008-2018), there has been a steady increase in the number of critical care fellows across specialties (CCM, pulmonary-CCM, emergency medicine-CCM, surgery, anesthesiology, pediatrics, and neonatology). There were 369 accredited adult and pediatric CCM training programs with 2023 fellows in 2008, which has increased by 25% to 462 programs with 3074 fellows in 2018. More than 80% of U.S. intensivists train in internal medicine CCM fellowship programs.