Health Affairs Blog: Rethinking ICU Allocation

Michael Nurok, MD, PhD, is the medical director of the Cardiac Surgery Intensive Care Unit in the Smidt Heart Institute. Photo by Cedars-Sinai.

Health Affairs, a blog that features commentary and analysis on health policy and issues affecting healthcare, recently featured an article by Michael Nurok, MD, PhD, medical director of the Cardiac Surgery Intensive Care Unit at the Smidt Heart Institute at Cedars-Sinai, about managing resources during crises like the COVID-19 pandemic.

In the article, Nurok highlights the challenges involved in deciding which patients receive ICU resources when healthcare facilities become overwhelmed. Across the United States, hospitals have adopted “allocation policies” to address these scenarios. The problem is that clinicians are quite limited in their ability to accurately determine which patients will benefit most from ICU care.

“When resources are scarce, clinicians are forced to choose between similar patients for whom there is potential benefit,” Nurok writes. Given the limitations of the predictive scoring system that tries to address who is likely to survive, Nurok recommends adopting an alternative approach. The U.S. has more than enough ICU beds to meet the needs of all of the nation's patients. However, ICU beds are allocated by individual hospital systems rather than as part of a comprehensive national or regional plan for confronting a crisis.

“A better approach is to consider allocation questions across the entire U.S. health care system,” he writes. “Doing so—although not without its challenges—would open up a larger pool of resources and allow us to make decisions about competing priorities as a society, ensuring that idle health care capacity is used and potentially averting vexing ethical decisions related to prognostic uncertainty.”

During the COVID-19 pandemic, state requirements for credentialing and licensing also hampered the ability of overwhelmed hospitals to staff critical-care locations, even as they expanded their physical capacity to handle patients.

Initially, credentialing and state licensing “prohibited skilled caregivers from less busy regions from quickly being relocated,” Nurok writes. “This created a maddening scenario of fallow ICU beds in the same locations where patients were struggling to access care.”

To address these issues and help prepare the U.S. healthcare system for future crises, Nurok makes three policy recommendations:

State and local officials should create comprehensive plans to move patients across regions when necessary.
States should address licensing, credentialing and payment barriers that hamper the quick and free movement of ICU caregivers between states and hospitals.
During a crisis, healthcare resources, such as ICU beds, and specialized machines, like ventilators, should be deployed on a national or regional basis.

“To better address future pandemics,” he writes, “we should consider allocation in ways that are more expansive, rather than limiting ourselves to those resources available to and directly controlled by an individual hospital.”

Click here to read the complete Health Affairs article.