ICU Boarders Get Subpar Care

When overcrowding forces intensive care patients to hospital outskirts, rounding providers get to them last and spend less face-to-face time.

There’s a practical reason why intensive care unit “boarders”—patients placed in alternate ICUs within a hospital—tend to suffer worse outcomes, according to a study published in the American Journal of Surgery.

“In this study, surgical ICU patients boarding in non-home units were more likely to be seen at the end of rounds, and on the whole received less bedside attention from ICU provider teams,” said lead author Andrew M. Nunn, MD, an assistant professor of Surgery at Wake Forest School of Medicine, who was a fellow in Traumatology at the Perelman School of Medicine at the time of the study.

According to the analysis of more than 500 rounding instances, that discrepancy can be quantified as follows:

• Caregivers spent about 16 percent less time on rounds with boarder patients, compared to non-boarding patients.
• About 71% of boarders were seen in the last fifth of rounds, compared to only about 13% of non-boarders.
• More boarders in an ICU also meant more use of the telephone, hinting at a greater reliance on “phone medicine” than face-to-face assessment.

Most simply, the distance between the home-ICU and boarding-ICU places an additional burden on home-ICU-based care providers, according to researchers. Additionally, home-ICU care teams may feel a reduced sense of “ownership” of patients housed in other ICUs; and nursing staff in boarding ICUs may not have the full skill set needed for the optimal care of their boarders.

“Together, all of these factors can create a ‘perfect storm’ leading to subpar clinical care of the critically ill patient,” said senior study author José L. Pascual, MD, PhD, FACS, FCCM, FRCSC, an associate professor of Traumatology, Surgical Critical Care and Emergency Surgery at Penn Medicine.

To mitigate these risks, providers at Penn Medicine’s surgical ICU, in addition to other interventions, are now encouraged to do rounds on boarding patients first rather than last.