Soft Calls

As an ICU fellow, I often get consulted to see a patient in the emergency department or floor who is in the gray zone of whether they need to come to the ICU. Perhaps the primary team feels like they have things under control but want another set of eyes. Maybe they could get worse, but it's pretty unlikely. Occasionally, the diagnosis is unclear so no one knows how sick they might become. We deal with this all the time: a patient who is septic from a urinary source but has no end-organ damage, a normal blood pressure, and normal lactate; a patient with hypoxia requiring noninvasive positive pressure ventilation that might just be turning around; a patient with diabetic ketoacidosis whose anion gap is on the way to closing.

In the vast majority of these cases, the patient would do fine in a step-down or monitored bed. Sometimes, while waiting for a bed, they get better in the emergency department. If they come to the ICU, they quickly leave once they are better.

Yet I take a large number of these patients to the ICU. Some of it is just uncertainty; if I am putting my name down as the responsible physician, I tend to be conservative and not risk sending them inappropriately to a lower level of care. Most of the time, I just want to play it safe. But there are a lot of arguments that this is the right way of using the ICU. Most patients with a dynamically changing disease process will either get worse or turn around within the first day of being in the hospital. This is the time period, the "golden hour," where our interventions matter. If we get them to the ICU and stabilize them, that's far more effective than having them get worse in a regular bed and bringing them up emergently. In that situation, we will have lost time, fumbled with transitions of care, and done the patient a disservice. In some eyes, the ICU is designed for the purpose of getting those critically ill patients better within the first day or two of presentation and then sending them to the floor. It's not designed for the chronically ill patients who stay for weeks on end.

I get a lot of criticism for this decision making though. My residents feel like they are getting extra work for a patient who is "not all that sick." Nurses and administrators may feel that I am not using resources appropriately. It's a strategy that doesn't really contain costs. This year as a fellow, I am sure I will become a little more nuanced with determining the disposition of those "soft call" patients in the gray zone.