Knowing Your Environment

Every hospital is different, and getting to know your hospital is a big part of being an ICU fellow. When we make decisions about a patient's "disposition" - that is, what level of care a patient needs - we have to be aware of our hospital's capability. I mention this because the VA is quite different than Stanford. The ICU at the VA often has patients whose acuity isn't all that high simply because they have specific nursing needs that only the ICU delivers such as hourly vascular checks. Patients that may go to the floor at other hospitals come to the unit at the VA. This also occasionally happens because the floor's ability to take care of sick patients is quite limited at the VA. I've often taken patient's to the ICU who might have stayed on the floor at a different hospital. This has a lot of implications, including cost considerations; an ICU bed uses a lot of resources and costs quite a bit, so having a system where a nonacute patient may take up slots might not be the most efficient. But it can also create an odd mix of patients in the unit. A patient may be moribund, on multiple intravenous pressors, mechanical ventilation, and dialysis, while his neighbor might be chatting, reading the morning newspaper, having breakfast, and simply having his pulses checked hourly. It's an odd unit in that respect. At times, I feel like I'm running a medicine ward service.

The other aspect of the VA is that it runs pretty close to capacity all the time. When patients come into the emergency department, I occasionally struggle to find them a bed. We wait for days to transfer patients out of the ICU. This, too, increases the cost of health care; we have patients who are appropriate for the floor taking up ICU resources simply because no other bed is available. Perhaps because the VA is not a profit-focused hospital, this is less important. However, considering our overall national expenditure on health care, we have to keep such things in mind.