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presence is required. Second, the checklist used by the study team has not been validated elsewhere, so Piquette et al ( 1 ) cannot completely be sure that they were actually measuring a surrogate of quality of care delivered to the simulated patients. However, the checklists do seem to have face and content validity, as they were developed by experts in the field. Finally, there is significant overlap in physical presence between the "direct" and "immediately available" groups, as 10 of the 16 residents in the "immediately available" group had their supervisor attend in-person within 5 minutes of the start of the scenario. Despite these limitations. Piquette et al (1) have moved us forward in attempting to answer a question that plagues all of us who work in teaching centers. Their results suggest that future performance by residents may not be adversely affected by the physical presence of a senior clinician. In other words, this concept of teaching residents "autonomy" may be overrated. Einally, using simulation to attempt to answer a real-life organizational problem is relatively novel. Using simulation allows researchers to manipulate the environment in ways not possible when studying real life. Therefore, the possibilities are almost endless when considering the many clinical and systems-based problems we could try to answer. Simulation is a powerful tool available to researchers, and we are only beginning to realize the potential of this tool.

REFERENCES 1. Piquette D, Tarshis J, Regehr G, et al: Effects of Glinical Supervision on Resident Learning and Patient Gare During Simulated IGU Scenarios. Crit Care Med 2013; 41:2705-2711 2. Pronovost PJ, Angus DG, Dormán T, et al: Physician staffing patterns and clinical outcomes in critically ill patients: A systematic review. JAMA 2002; 288:2151-21 62 3. Wallace DJ, Angus DG, Barnato AE, et al: Nighttime intensivist staffing and mortality among critically ill patients. N Engi J Med 2012; 366:2093-2101 4. Garland A, Roberts D, Graff L: Twenty-four-hour intensivist presence: A pilot study of effects on intensive care unit patients, families, doctors, and nurses. Am J Respir Crit Care Med 2012; 185:738-743 5. van der Wilden GM, Schmidt U, Ghang Y, et al: Implementation of 24/7 intensivist presence in the SIGU: Effect on processes of care. J Trauma Acute Care Surg 2013; 74:563-567 6. Kerlin MP, Small DS, Gooney E, et al: A randomized trial of nighttime physician staffing in an intensive care unit. N Engi J Med 2013; In Press 7 Angus DG, Shorr AF, White A, et al; Gommittee on Manpower for Pulmonary and Gritical Gare Societies (GOMPAGGS): Gritical care delivery in the United States: Distribution of services and compliance with Leapfrog recommendations. Crit Care Med 2006; 34:1016-1024 8. Parshuram GS, Kirpalani H, Mehta S, et al; Ganadian Gritical Gare Trials Group: In-house, overnight physician staffing: A cross-sectional survey of Ganadian adult and pédiatrie intensive care units. Crit Care Med 2006; 34:1674-1678 9. Kim J, Neilipovitz D, Gardinal P, et al: A pilot study using high-fidelity simulation to formally evaluate performance in the resuscitation of critically ill patients: The University of Ottawa Gritical Gare Medicine, High-Fidelity Simulation, and Grisis Resource Management I Study. Crit Care Med 2006; 34:21 67-2174

Goldilocks in the ICU: Too Few Beds, Too Many, or Just Right?* Emily Damuth, MD Christa A. Schorr, RN, MSN, FCCM Division of Critical Care Department of Medicine Cooper University Health Care Cooper University Hospital Camden, NJ

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ptimizing access to healthcare, while attempting to control costs, is a constant tug-of-war in the United States, as well as internationally. However, in pursuit of this balance, the United States actually spends more than any other nation on intensive care, totaling over 13% of

*Seealsop. 2712. Key Words: beds; IGU; mechanical ventilation; occupancy; rationing The authors have disclosed that they do not have any potential conflicts of interest. Gopyright © 2013 by the Society of Gritical Gare Medicine and Lippincott Williams & Wilkins DOI: 10.1097/CCM.ObOI 3e31829cb2aO

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hospital costs and nearly 1% of the gross domestic product (1). Furthermore, there are seven times as many ICU beds per capita in the United States than in the United Kingdom. Perhaps due to greater critical care bed availability, ICU admissions in the United States have lower severity of illness scores and hospital mortality when compared internationally. However, these data may have been confounded by international variance in admission and discharge practices. As one study demonstrated, a greater proportion of patients in the United States are admitted to the ICU directly from the emergency department (ED) and discharged to skilled nursing facilities with a higher severity of illness and shorter length of stay than their U.K. counterparts (2). Do greater critical care spending and ICU beds per capita translate to surge capacity capable of handling massive casualties in the United States? In the wake of the Boston bombings, these questions strike an emotional chord and demand answers. These are the very questions that Wunsch et al (3) investigated in this issue of Critical Care Medicine. The authors performed a retrospective cohort study using a database (Project Impact) of 97 participating U.S. ICUs to December 2013 • Volume 41 • Number 1 2

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determine hourly bed occupancy and mechanical ventilator use. They also sought to quantify the proportion of patients whose admission could possibly be deferred in times of critical bed shortage, such as planned admissions following elective surgery. The authors found that ICU occupancy in the United States ranged from 57.4% to 82.1% with 20.7% to 28.9% of all patients receiving mechanical ventilation from 2005 to 2007. Academic hospitals had both the highest occupancy and mechanical ventilation rates (78.7% and 41%, respectively). Wunsch et al concluded that on average only two thirds of beds were occupied at any given time, and only one third of these beds held patients requiring mechanical ventilation. They note that a substantial percentage of patients were admitted after elective surgery (18.1%) and for observation (34.5%), suggesting that these admissions might be deferrable in the face of an epidemic or disaster. Based on their findings, the authors project that nearly 20,000 adult ICU beds are available at a given time, which they describe as "substantial excess capacity." Although the findings of the current study are in line with previous reports estimating ICU occupancy in the United States around 65% (4), the authors' conclusions regarding excess capacity for massive casualty events might be overly optimistic. Bed occupancy has not been universally adopted as the most accurate metric for "capacity strain" in the ICU. Occupancy has been criticized as a limited measure of capacity strain because it equates new admissions with stable patients awaiting transfer, overlooks "flex" beds that can be used during periods of overcrowding, and fails to quantify patient acuity (5). When patient volume and acuity outstretch an institution's critical care resources, care delivered inside and outside the ICU degrades. This concept has been cleverly described as the Starling curve for intensive care (6). In fact, the overall odds of death increases by a factor of 3 for patients denied admission to the ICU (7). Prior studies have also correlated increased occupancy with greater acuity. A multicenter observational study conducted in 12 European countries demonstrated that ICU occupancy greater than 80% was associated with increased mortality (8). However, the occupancy threshold for mortality in the United States remains unclear. Inadequate ICU capacity increases mortality not only in patients denied admission to the ICU but also in those whose admission is delayed, which increases ED boarding time (9). Interestingly, a study by Iwashyna et al (10), which measured capacity strain by volume of ICU census, found that mortality did not differ for patients admitted to the ICU on low- versus high-census days. Vast differences exist internationally in the provision of critical care beds, thus the ideal occupancy and number of beds per capita remain elusive. The demand for critical care

Critical Care Medicine

beds in the future is growing, not shrinking. Moving forward, our aging U.S. population will only require more ICU-level care and prolonged mechanical ventilation. Already, almost two thirds of all ICU admissions in the United States are over the age of 60 ( 11 ). Rationing critical care services, rather than excess, will likely predominate future discussions, undoubtedly with ensuing ethical debate (12). Not only are large ICUs more costly, but greater critical care capacity may lead to delivery of more aggressive care in a delicate patient population potentially going beyond the intended wishes of patients/families with greater risk of iatrogenic complications. Wunsch et al provide extensive insight into ICU bed occupancy and mechanical ventilator use in the United States across all unit types. However, they also astutely point out that availability of trained critical care providers is more likely to limit disaster preparedness than provision of fixed resources, such as the number of ICU beds and ventilators. Perhaps what we have learned from goldilocks in the ICU is that comfortable critical care bed supply comes at a cost and occupancy may not be the best metric for determining "just right." The end to this fairytale remains to be told.

REFERENCES 1. Halpern NA, Pastores SM: Critical care medicine in the United States 2000-2005: An analysis of bed numbers, occupancy rates, payer mix, and costs. Crit Care Med 2010; 38:65-71 2. Wunsch H, Angus DC, Harrison DA, et al: Comparison of medical admissions to intensive care units in the United States and United Kingdom. Am J Respir Crit Care Med 2011 ; 183:1 666-1673 3. Wunsch H, Wagner J, Herlim M, et al: ICU Occupancy and Mechanical Ventilator Use in the United States. Crit Care Med 2013; 41:2712-2719 4. Halpern NA, Pastores SM, Thaler HT, et al: Changes in critical care beds and occupancy in the United States 1985-2000: Differences attributable to hospital size. Crit Care Med 2006; 34:2105-2112 5. Halpern SD: ICU capacity strain and the quality and allocation of critical care. Curr Opin Crit Care 2011 ; 17:648-657 6. Wunsch H: Is there a Starling curve for intensive care? Chest 2012; 141;1393-1399 7 Sinuff T, Kahnamoui K, Cook DJ, et al; Values Ethics and Rationing in Critical Care Task Force; Rationing critical care beds: A systematic review. Crit Care Med 2004; 32:1 588-1597 8. lapichino G, Gattinoni L, Radrizzani D, et al: Volume of activity and occupancy rate in intensive care units. Association with mortality. intensive Care Med 2004; 30:290-297 9. Chalfin DB,TrzeciakS, LikourezosA, etal; DELAY-ED study group: Impact of delayed transfer of critically ill patients from the emergency department to the intensive care unit. Crit Care Med 2007; 35:1477-1483 10. Iwashyna TJ, Kramer AA, Kahn JM: Intensive care unit occupancy and patient outcomes. Crit Care Med 2009; 37:1545-1557 11. Hamel MB, Phillips RS, Teno JM, et al: Seriously ill hospitalized adults: Do we spend less on older patients? Support Investigators. Study to Understand Prognoses and Preference for Outcomes and Risks of Treatments. J Am Geriatr Soc 1996; 44;1043-1048 12. Truog RD, Brock DW, Cook DJ, et al; Task Force on Values, Ethics, and Rationing in Critical Care (VERICC): Rationing in the intensive care unit. Crit Care Med 2006; 34:958-963; quiz 971

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Goldilocks in the ICU: too few beds, too many, or just right?

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