INFLUENCE OF POLITICAL-POWER, MEDICAL PROVINCIALISM, AND ECONOMIC INCENTIVES ON THE RATIONING OF SURGICAL INTENSIVE-CARE UNIT BEDS

Objective: To determine factors influencing rationing decisions in a surgical ICU during a temporary nursing shortage when two to six of the unit's 16 beds were closed. Design: Blinded, concurrent data collection, retrospective chart review. Setting: Surgical ICU. Patients: All patients (n = 308) for whom a surgical ICU bed was requested were studied during a 3-month period. Measurements and Main Results: 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 surgical ICU beds. Contrary to findings in previous reports, the severity of illness of patients admitted to the surgical ICU decreased as bed availability and bed census decreased. Bed allocation across surgical services was influenced by factors other than medical suitability. Of major users, cardiothoracic surgery experienced the highest percentage (59%) of all patient admissions and lowest percentage (1.6%) of all denied admissions. General surgery experienced the lowest percentage (15%) of all admissions and highest percentage (10.4%) of all denied admissions, although these patients had the highest average Acute Physiology and Chronic Health Evaluation (APACHE II) scores for all patients admitted (17.7) and for patients denied admission (15.8). Conclusions: Surgical attending physicians rarely used other open inhouse ICU beds when surgical ICU beds were unavailable. Political power, medical provincialism, and income maximization overrode medical suitability in the provision of critical care services.