The Urge to Build More Intensive Care Unit Beds and Ventilators: Intuitive but Errant
Authors: Scott D. Halpern, Franklin G. Miller
Journal: Annals of Internal Medicine (2020)

Ideas and Opinions18 August 2020The Urge to Build More Intensive Care Unit Beds and Ventilators: Intuitive but ErrantFREEScott D. Halpern, MD, PhD and Franklin G. Miller, PhDScott D. Halpern, MD, PhDUniversity of Pennsylvania, Philadelphia, Pennsylvania (S.D.H.) and Franklin G. Miller, PhDWeill Cornell Medical College, New York, New York (F.G.M.)Author, Article, and Disclosure Informationhttps://doi.org/10.7326/M20-2071 SectionsAboutVisual AbstractPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissions ShareFacebookTwitterLinkedInRedditEmail Throughout the coronavirus 2019 (COVID-19) crisis, much attention has been devoted to the fraught question of how to allocate intensive care unit (ICU) beds and mechanical ventilators if the supply of these resources is insufficient to provide them to all patients considered to be in need. Contemplating such tragic choices naturally conjures thoughts that we might have avoided these dilemmas by rapidly manufacturing new beds and ventilators at the first sign of a looming pandemic, or by rapidly converting existing beds and machines such that they could be used to expand the supply of critical care resources. These ideas stem from the natural human heuristic and conventional clinical ethos to mount unstinting effort toward saving the lives of those who fall ill. These views are also psychologically reinforced by the instinct to deploy aggressive medical technology to win the "war" against the pandemic.Indeed, the instinct to save the lives of the desperately ill, which exemplifies the "rule of rescue" (1), is so intuitively powerful as to make it hard for humans to even consider competing approaches. No one would condone a response to the COVID-19 pandemic that did not include using the nation's full supply of critical care resources. However, the drive to build even more beds and ventilators will do more to assuage public anxiety and outrage than to reduce overall mortality, owing to both the poor outcomes among patients with COVID-19 receiving mechanical ventilation and the diversion of clinical workforces.We argue that supply-side investments in critical care in the midst of the pandemic would not substantially improve population health in the short term and would worsen it in the long term. As psychologically disruptive as it may be to consider not expanding the critical care supply, such expansions would magnify the already considerable skew of U.S. health care toward intensive care. We further argue that even modest improvements in public health measures, such as physical distancing (which might be promoted by infomercials featuring sports or movie stars) and training more health care workers to become expert in serious illness communication, would be more effective than investments in critical care for improving short-term population health.Before COVID-19, the United States had more ICU beds and ventilators per capita than nearly any other country (2). Indeed, an assessment of ICU occupancy and ventilator use revealed that during noncrisis times, the United States has a glut of critical care resources. In any given hour, only two thirds of ICU beds are occupied and only one third are occupied by patients receiving mechanical ventilation (3). Although these numbers have been starkly different during the COVID-19 crisis, they highlight our substantial existing capacity to care for those most likely to benefit from critical care.As a result of this extant capacity, adding ventilators and ICU beds would make critical care delivery less efficient. Indeed, many studies have shown that when ICU beds are tight, critical care is increasingly allocated to patients who benefit from it, without increasing overall mortality (4–6). Building more beds and ventilators would offset these efficiencies of scarcity, increasing the already high mortality rates observed among patients with COVID-19 who require mechanical ventilation (7). Although the total number of survivors might increase to an extent, so too would the burden of chronic critical illness.The second reason that building more ICU beds and ventilators will not deliver the hoped-for life savings is that they are not the scarcest resources during the current pandemic. Most projections indicate that ward beds and healthy critical care clinicians will be more scarce than ICU beds or ventilators (8). Thus, expansions to the ventilator supply may carry adverse consequences for population health by requiring the redeployment of non–critical care clinicians and beds, such that non–critically ill patients may become critically ill and even die.Such workforce redeployment reveals a third reason to doubt the benefits of increasing critical care capacity: the adverse consequences for clinician effectiveness and well-being. Although building beds and ventilators may prevent the moral distress that certain clinicians would otherwise feel in having to make life-or-death choices about allocation, redeployment would likely increase burnout among clinicians who are unaccustomed to working in critical care environments. Asking physicians who have not contemplated a ventilator since medical school to manage the sickest ventilated patients, particularly without adequate personal protective equipment, could adversely affect the long-term health of the clinical workforce.Fourth, every dollar spent building more ICU beds and ventilators would save more lives if instead spent on more testing for severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), contact tracing, and personal protective equipment, or on promoting adherence to physical distancing. Indeed, using the COVID-19 Hospital Impact Model for Epidemics (8), we projected that even a doubling of the ventilator supply would not save as many lives as a 40% decrease in physical contact. And the sooner in a region's epidemic trajectory such policies were implemented, the greater the benefit of distancing, and the less the benefit of ventilator production.Other, less obvious initiatives might also yield greater benefits to short-term population health. For example, palliative care clinicians and others with excellent skills in serious illness communication and symptom management are among the scarcest of all health care resources (9). Thus, COVID-19 leads us to utilize our preexisting glut of critical care resources, but it also magnifies the preexisting shortage of palliative care clinicians. Although expanding the palliative care workforce will not save lives, it may offer a societal investment superior to that of critical care expansion, given the resultant benefits in quality of life for patients and their family caregivers.Finally, in a nation in which nearly 1% of gross domestic product is already allocated to critical care, further growth should be approached with extreme reticence. History suggests that any COVID-19–induced expansions to the critical care supply may unfortunately be hard to reverse once the pandemic ends. Supply-induced demand—or, "if you build it, they will come"—was a hallmark of U.S. critical care well before COVID-19 (10). Having experienced this pandemic, we will find it difficult to shrink the critical care supply for fear of being underprepared for the next pandemic.Our natural moral reasoning precludes us from withholding available critical care, even from patients with remote chances of benefiting from it, and the same reasoning motivates us to expand critical care during times of need. But even if building more ICU beds and ventilators neither crowded out opportunities for other more effective initiatives nor exacerbated critical care excesses in the future, it would ultimately represent the triumph of deeply human instincts over optimal policy.References1. Jonsen AR. Bentham in a box: technology assessment and health care allocation. Law Med Health Care. 1986;14:172-4. [PMID: 3645228] CrossrefMedlineGoogle Scholar2. Wunsch H, Angus DC, Harrison DA, et al. Variation in critical care services across North America and Western Europe. Crit Care Med. 2008;36:2787-93, e1-9. [PMID: 18766102] doi:10.1097/CCM.0b013e318186aec8 CrossrefMedlineGoogle Scholar3. Wunsch H, Wagner J, Herlim M, et al. ICU occupancy and mechanical ventilator use in the United States. Crit Care Med. 2013;41:2712-9. [PMID: 23963122] doi:10.1097/CCM.0b013e318298a139 CrossrefMedlineGoogle Scholar4. Wagner J, Gabler NB, Ratcliffe SJ, et al. Outcomes among patients discharged from busy intensive care units. Ann Intern Med. 2013;159:447-55. [PMID: 24081285]. doi:10.7326/0003-4819-159-7-201310010-00004 LinkGoogle Scholar5. Wagner J, Halpern SD. Deferred admission to the intensive care unit: rationing critical care or expediting care transitions? Arch Intern Med. 2012;172:474-6. [PMID: 22412077] doi:10.1001/archinternmed.2012.114 CrossrefMedlineGoogle Scholar6. Anesi GL, Admon AJ, Halpern SD, et al. Understanding irresponsible use of intensive care unit resources in the USA. Lancet Respir Med. 2019;7:605-612. [PMID: 31122898] doi:10.1016/S2213-2600(19)30088-8 CrossrefMedlineGoogle Scholar7. Richardson S, Hirsch JS, Narasimhan M, et al; Northwell COVID-19 Research Consortium. Presenting characteristics, comorbidities, and outcomes among 5700 patients hospitalized with COVID-19 in the New York City area. JAMA. 2020. [PMID: 32320003] doi:10.1001/jama.2020.6775 CrossrefMedlineGoogle Scholar8. Weissman GE, Crane-Droesch A, Chivers C, et al. Locally informed simulation to predict hospital capacity needs during the COVID-19 pandemic. Ann Intern Med. 2020. [PMID: 32259197]. doi:10.7326/M20-1260 LinkGoogle Scholar9. Courtright KR, Cassel JB, Halpern SD. A research agenda for high-value palliative care. Ann Intern Med. 2018;168:71-72. [PMID: 29132161]. doi:10.7326/M17-2164 LinkGoogle Scholar10. Gooch RA, Kahn JM. ICU bed supply, utilization, and health care spending: an example of demand elasticity. JAMA. 2014;311:567-8. [PMID: 24408679] doi:10.1001/jama.2013.283800 CrossrefMedlineGoogle Scholar Comments0 CommentsSign In to Submit A Comment Neelesh Gupta (1), Samer Ellahham (2), Rajeev Gupta (3)(1) Nazareth Hospital, Philadelphia, PA, USA., (2) Cleveland Clinic, Abu Dhabi, UAE, (3) Mediclinic Al-Jowhara Hospital, Al Ain, UAE24 July 2020 The pandemics are fought outside the hospitals, not inside We read with interest the idea and opinion "The Urge to Build More Intensive Care Unit Beds and Ventilators: Intuitive but Errant". The idea is laudable. We may add that pandemics are fought in the fields and not in the hospitals, and the best weapons are easy-to-understand education, timely implementation of sound policies, cooperation, and compliance by the public globally. This policy is conspicuously missing even in many developed countries. Unless good examples are set by the celebrities and policymakers, it may be hard to contain the pandemic. Disclosures: The authors have nothing to disclose. Author, Article, and Disclosure InformationAffiliations: University of Pennsylvania, Philadelphia, Pennsylvania (S.D.H.)Weill Cornell Medical College, New York, New York (F.G.M.)Disclosures: Authors have disclosed no conflicts of interest. Forms can be viewed at www.acponline.org/authors/icmje/ConflictOfInterestForms.do?msNum=M20-2071.Corresponding Author: Scott D. Halpern, MD, PhD, University of Pennsylvania Perelman School of Medicine, 301 Blockley Hall, 423 Guardian Drive, Philadelphia, PA 19104-6021; e-mail, [email protected]edu.Current Author Addresses: Dr. Halpern: University of Pennsylvania Perelman School of Medicine, 301 Blockley Hall, 423 Guardian Drive, Philadelphia, PA 19104-6021.Dr. Miller: 435 East 70th Street, 4-J, New York, NY 10021.Author Contributions: Conception and design: S.D. Halpern, F.G. Miller.Analysis and interpretation of the data: S.D. Halpern.Drafting of the article: S.D. Halpern, F.G. Miller.Critical revision of the article for important intellectual content: S.D. Halpern, F.G. Miller.Final approval of the article: S.D. Halpern, F.G. Miller.Obtaining of funding: S.D. Halpern.Administrative, technical, or logistic support: S.D. Halpern.This article was published at Annals.org on 7 May 2020. PreviousarticleNextarticle Advertisement FiguresReferencesRelatedDetails Metrics Cited byChallenging the logic of lifesaving in the intensive care unitDevelopment of an Index to Assess COVID-19 Hospital Care Installed Capacity in the 450 Brazilian Health RegionsBehavioral Economics in the Epidemiology of the COVID-19 Pandemic: Theory and SimulationsA systematic review of de-escalation strategies for redeployed staff and repurposed facilities in COVID-19 intensive care units (ICUs) during the pandemicML-Enabled Informed Intervention for Crowdsourcing-Based Optimization of Medical ResourcesCOVID-19: Rethinking the Lockdown GroupthinkICU beds: less is more? Not sure 18 August 2020Volume 173, Issue 4Page: 302-303KeywordsCOVID-19Communication in health careCritical careHealth careInstinctIntensive care unitsPalliative carePersonal protective equipmentReasoningVentilators ePublished: 7 May 2020 Issue Published: 18 August 2020 Copyright & PermissionsCopyright © 2020 by American College of Physicians. All Rights Reserved.PDF downloadLoading ...