Abstract and Introduction
Abstract
Objective: To determine the relationship between hospital size and changes in the number of critical care medicine (CCM) beds, proportion of hospital beds allocated to CCM, and CCM occupancy in acute care hospitals in the United States from 1985 to 2000.
Design: A 16-yr (1985 to 2000) retrospective analysis was performed using the Hospital Cost Report Information System (Centers for Medicare and Medicaid Services, Baltimore, MD) on U.S. acute care hospitals that provided CCM. Hospitals were stratified into four groups (small, 1-100 beds; medium, 101-300 beds; large 301-500 beds; and extra large, >500 beds).
Setting: Nonfederal, acute care hospitals with CCM units in the United States.
Subjects: None.
Interventions: None.
Measurements: Changes in the number of hospitals, non-CCM and CCM beds, the proportion of CCM to hospital beds, and their occupancy rates.
Main Results: Between 1985 and 2000, the number of hospitals providing CCM decreased overall (4,150 to 3,581, -13.7%). The greatest decreases were seen in large (-39%) and extra-large (-40%) hospitals. Small hospitals increased minimally (3.3%). The number of non-CCM beds decreased (820,300 to 566,900, -30.9%), most prominently in large (-44.2%) and extra-large (-46.1%) hospitals. In contrast, CCM beds increased overall (69,300 to 87,400, 26.1%), especially in small (27%) and medium (44.2%) hospitals. The proportion of total hospital beds assigned to CCM increased (71.8%), most markedly in large (93.5%) and extra-large (85.7%) hospitals. Non-CCM occupancy decreased (-6.4%), particularly in small (-7.5%) and extra-large (-5.8%) hospitals. However, regardless of hospital size, CCM occupancy changed negligibly (0.4%). At every time point studied, CCM occupancy was greater than non-CCM occupancy within each size group. As hospital size increased, occupancy rates increased.
Conclusions: Across hospitals of all sizes, CCM bed numbers are increasing, whereas non-CCM bed numbers are decreasing. Although the CCM bed capacity is increasing at a greater percentage rate in smaller hospitals, the assignment of hospital beds to CCM remains higher in the larger hospitals. In addition, CCM bed occupancy is greater in larger institutions. These findings may help guide the future development of hospital size-based CCM benchmarking standards and guidelines.
Introduction
The past two decades have witnessed the increasingly prominent role of critical care medicine (CCM) in acute care hospitals in the United States . Between 1985 and 2000, the percentage of hospital beds used by CCM in acute care hospitals increased by 71.8% (7.8% to 13.4%). This occurred as a consequence of two divergent trends in bed numbers; CCM beds increased by 26% (69,300 to 87,400), whereas non-CCM beds decreased by 31% (820,300 to 566,900). Despite these large opposing fluxes in bed numbers, CCM occupancy remained constant at 65%, whereas non-CCM occupancy decreased minimally from 61% to 57% . By 2000, CCM consumed 13.3% ($55.5 billion) of hospital costs ($416.5 billion) and 0.56% of the gross domestic product ($9.8 trillion).
There are persistent concerns about CCM's evolving role in inpatient care, hospital organizational infrastructure, bed allocation, bed use and occupancy, and hospital throughput. National CCM care, safety, and design initiatives and guidelines have been introduced to address these problems. In addition, to better understand the CCM landscape, three national CCM benchmark studies have been performed. In 1991 and 2003 the Society of Critical Care Medicine (SCCM) conducted 1-day snapshot surveys of CCM variables in U.S. hospitals. In 2001, the Solucient Company, using Medicare data sets from 1998 to 1999, released a report that analyzed CCM outcome measures in selected acute care U.S. hospitals. These studies assessed CCM variables or outcome measures by either hospital size or type, but they had several methodologic limitations. First, all U.S. acute care hospitals were not included because participation in the SCCM or Solucient studies was either voluntary or preselected, respectively; thus, the results may not be universally applicable. Second, trends cannot be identified, as only two brief time periods were evaluated, 1 day or 1 yr. Finally, because of study group incompatibility, meta-analyses are not possible.
The purpose of this study was to provide a fully inclusive, long-term, and consistent benchmark analysis of CCM in the United States stratified by hospital size. Using our established hospital database derived from the U.S. government's Hospital Cost Report Information System (HCRIS), we stratified all acute care hospitals with CCM beds into four hospital size groups. We then analyzed the changes in CCM and hospital beds, their ratio, and their use in the United States during a 16-yr period (1985 to 2000).