Strategic solutions for the daily challenges of qualified intensive care unit beds and team shortages in hospitals

ABSTRACT

No single, universal solution addresses the growing problem of hospital boarding amid constrained critical care resources. Throughout this text, we explored practical strategies aligned with this philosophy: early stabilization in Emergency Departments through specialized critical care teams; structured use of intermediate care units; tele-critical care networks extending intensivist oversight; hospital-based palliative care integration; automated early warning systems; robust rapid response systems and outreach teams; optimized perioperative triage; and governance reforms through closed or semi-closed intensive care unit models.

Keywords:
Quality of care; Sepsis; Palliative care; Triage; Emergency Service, Hospital; Critical care; Phylosophy; Hospitals; Intensive care units

BACKGROUND

The growing mismatch between demand for critical care and available intensive care unit (ICU) capacity is driven by population aging and the increasing burden of chronic disease, creating major clinical and financial pressure on hospital systems.¹ Delays in ICU admission, premature ward discharge, and ICU overcrowding have been associated with worse outcomes and operational inefficiencies, including postponement of high-risk surgeries and inappropriate resource utilization.²-⁴ Importantly, many patients requiring close monitoring do not necessarily need full ICU-level care, and several conditions may be safely managed in lower-intensity settings after initial stabilization.⁵,⁶ Despite this, ICU bed expansion remains a common response in many healthcare systems.⁷ However, greater ICU availability has not consistently translated into better outcomes and may increase costs and workforce demands.⁸,⁹

These findings suggest that ICU capacity constraints are not solely structural, but also reflect inefficiencies in patient flow, triage, and care transitions. Consequently, strategies aimed at improving operational performance - such as reducing delays and optimizing resource utilization - should be evaluated separately from their effects on patient-centered outcomes, which remain heterogeneous and context-dependent. Improving critical care delivery therefore requires coordinated system-level approaches focused on early recognition, standardized management, and flexible infrastructure capable of initiating timely interventions before ICU admission becomes necessary.¹⁰,¹¹ Care bundles for conditions such as sepsis and acute kidney injury exemplify this approach and have been associated with improved outcomes in selected settings.¹²,¹³

In parallel, selected organ support strategies - including high-flow nasal oxygen, noninvasive ventilation, and peripheral vasopressor administration - can be safely implemented outside the ICU in appropriately monitored environments.¹⁴,¹⁵Many hospitals have also developed enhanced care areas within general wards, supported by monitoring systems and Critical Care Outreach Teams (CCOT), to improve continuity of care and reduce reliance on traditional ICU beds.¹⁶

We selected the strategies discussed in this manuscript based on their relevance to ICU capacity management, feasibility across different healthcare settings, and the availability of operational or clinical evidence supporting their use within a systems-based framework. We included strategies with limited or heterogeneous evidence when they showed biological or organizational plausibility or were consistently associated with improvements in process-related outcomes. Accordingly, this review examines practical and cost-effective alternatives to routine ICU bed expansion, particularly relevant for low- and middle-income settings. For conceptual clarity, the proposed strategies are organized into three domains: early identification and stabilization, intermediate and flexible care pathways, and system-level coordination (Figure 1).

Figure 1
Illustrates an integrated operational framework demonstrating how these strategies interact within a hospital system under the ‘intensive care unit without walls’ paradigm.

ICU - intensive care unit; MEWS - Modified Early Warning Score; NEWS - National Early Warning Score; CCOT - critical care outreach team; RRS - rapid response systems.

Specialized critical care teams in the Emergency Department

Prolonged boarding in the Emergency Department (ED) has been consistently associated with delays in essential interventions, fragmented care, and increased pressure on frontline teams.¹⁷,¹⁸ These delays may trigger a cascade of adverse effects, compromising patient safety and clinical outcomes. In response, healthcare systems have increasingly explored strategies to strengthen early critical care delivery within the ED. Among these, implementing specialized critical care teams has emerged as a pragmatic approach to mitigate the impact of boarding by ensuring timely evaluation and management by clinicians trained in acute and critical care. A recent systematic review of predominantly retrospective observational studies reported an association between delayed ICU transfer and a 61% increase in mortality risk; however, given the observational nature of the underlying evidence, this finding should be interpreted as associative rather than causal.¹⁹

Different organizational models have been developed to operationalize ED-based critical care, ranging from mobile consultation teams to dedicated high-acuity areas and fully integrated ED-ICU units (Tables 1 and 2).²⁰ Despite differences in complexity and resource requirements, these models share a common goal: to provide flexible, high-acuity care that improves early stabilization and supports more efficient patient flow, including the avoidance of unnecessary ICU admissions when clinically appropriate.

Table 1
Models for delivering critical care in the Emergency Department(20)

Model	Definition	Characteristics	Results
Emergency Department-based intensivist consultations (Table 2)	A CC-physician trained in emergency medicine, along with a dedicated CC-nurse, are embedded within the ED to offer prompt consultations and interventions for critically ill patients, eliminating the need for a separate ICU space or specialized equipment	Low number of resources utilized No modifications are needed to meet the hospital’s requirements	Possible reduction in in-hospital mortality Possible reduction in short-stay ICU admissions
Emergency Department-ICU model	The attending physician team consists of board-certified EM physicians available 24/7. At the same time, the nursing staff includes ED nurses with CC training and a dedicated orientation program, along with a respiratory therapist and pharmacist assigned to the main ED	The increase in healthcare professionals and the need for a dedicated ED area were required. However, it was not associated with significant changes in inflation-adjusted total direct costs per ED encounter	Possible reduction in risk-adjusted short-term mortality among ED patients Possible reduction in ICU admissions among patients evaluated in the Emergency Department Possible reduction in short-stay ICU admissions
Hybrid model	It combines elements of an ED-based intensivist consultation service with specialized nursing support, offering extended care in a resuscitation bay or ED area with enhanced monitoring and staffing	It is a consultancy service led by an EM/CC dual-boarded physician that delivers prompt, targeted care to patients early in critical illness	Possible provision of care comparable to that delivered in traditional inpatient ICUs for critically ill patients boarding in the Emergency Department No consistent differences in hospital or ICU length of stay, duration of mechanical ventilation, or overall mortality
Critical care resuscitation unit	EM intensivists staff it	It focuses on receiving outside hospital transfers requiring urgent surgical interventions; or ischemic strokes from large vessel occlusion who are thrombectomy candidates(19) or to attend to critically ill patients with gastrointestinal bleeding	Possible reduction in hospital length of stay

• CC - critical care; ED - Emergency Department; ICU - intensive care unit; EM - Emergency Medicine.

Table 2
Different models in Emergency Department-based intensivist consultations

Model	Description	Advantages	Disadvantages
Critical care bedside consultation team	A mobile team of critical care specialists who respond to consultation requests in the ED or other hospital areas	Flexible and can assist across multiple areas Cost-effective, as it requires no dedicated infrastructure Supports ED patient flow	Limited availability if the team is occupied Relies on existing ED infrastructure, which may not support high-acuity needs
Critical Care Team in a high-acuity monitored area	A designated high-acuity area within the ED, staffed by a critical care team and equipped for advanced care	Specialized monitoring and equipment for critically ill patients Reduces delays by keeping patients close to ED resources Facilitates rapid stabilization	Requires significant investment in infrastructure and staffing May not provide full ICU-level interventions Risk of bottlenecks during peak demand
Fully integrated ICU within the ED	A fully equipped intensive care unit located within the ED, designed to provide comprehensive ICU-level care	Immediate access to ICU resources and staff Minimizes delays in critical care Reduces ED workflow disruptions	High cost due to infrastructure, equipment, and staffing needs Risk of underutilization during low demand periods Potential overlap with the main ICU

• ED - Emergency Department; ICU - intensive care unit.

This approach is supported by the observation that a substantial proportion of ICU admissions involve conditions requiring only short-term intensive management. In large cohorts, up to 38% of admissions have been classified as short-stay ICU episodes,²¹ and several common acute conditions - such as diabetic ketoacidosis, sepsis, or exacerbations of chronic cardiopulmonary disease - may stabilize rapidly with targeted interventions.⁵,⁶,²²,²³ In selected cases, step-down strategies, including noninvasive ventilation, post-extubation monitoring, or structured palliative pathways, can be safely delivered outside the ICU when adequate monitoring and expertise are available.²⁴,²⁵

Beyond individual patient management, ED-based critical care models may also improve system performance. In overcrowded settings, redirecting high-acuity patients to dedicated teams or areas can reduce the cognitive and operational burden on ED staff, improve continuity of care during transitions, and potentially decrease fragmentation and handoffs.²⁴,²⁶,²⁷ However, these benefits must be balanced against important limitations. Implementing ED-ICU models requires substantial infrastructure, sustained financial investment, and a specialized workforce. Moreover, their impact on clinical outcomes appears heterogeneous, and not all patient populations derive consistent benefit compared with optimized early management and timely ICU transfer.²⁸,²⁹

Overall, ED-based critical care should be viewed not as a universal solution, but as one component of a broader system-level strategy to improve early stabilization, optimize patient flow, and reduce unnecessary reliance on ICU beds. Its effectiveness ultimately depends on integration with downstream care pathways, institutional resources, and local organizational context.

Intermediate care supporting critical ill patients

The development of intermediate care (IC) units reflects recognition that, although ICUs are essential for life-saving interventions, they are resource-intensive and capacity-limited. Intermediate care services - also referred to as high-dependency or step-down units - are designed for patients who do not require full ICU support but whose needs exceed the capabilities of standard wards.³⁰ These units typically provide enhanced monitoring and selected organ support, offering a potential alternative for patients at lower risk of rapid deterioration.

However, IC organization varies widely across institutions, including standalone units, integration within ICUs, or implementation within general wards.³¹ This heterogeneity extends to staffing models and operational structures, reflecting differences in resources, case mix, and local healthcare systems.³⁰ As a result, direct comparisons between models are limited, and their generalizability remains uncertain.

The clinical impact of IC units remains debated. Studies evaluating direct admission to IC instead of ICU have not consistently demonstrated clear benefits in patient-centered outcomes.³² In contrast, their role as a structured step-down pathway for patients recovering from critical illness appears more consistent, supporting safer transitions and reducing premature discharge to general wards.³³These findings suggest that the effectiveness of IC may depend less on its existence as a distinct unit and more on how it is integrated within the broader care continuum.

From an economic perspective, IC implementation presents important trade-offs. Expanding IC capacity without reducing ICU beds is likely to increase overall costs, given the need for higher staffing ratios and additional infrastructure compared with standard wards. Nevertheless, in selected patient populations with predictable clinical trajectories - such as diabetic ketoacidosis, fluid-responsive sepsis, or exacerbations of chronic respiratory disease - IC may represent a cost-effective alternative to ICU admission while maintaining safety.³⁴ Current guidelines emphasize appropriate patient selection but provide limited guidance on operational aspects such as monitoring intensity, geographic organization, and staffing models.³⁵,³⁶ Importantly, patient trajectory - an essential determinant of safe triage and resource allocation - is not consistently incorporated into these frameworks.

Overall, IC should not be viewed as a uniform solution, but as a flexible component of a system-level strategy to optimize ICU capacity. Its value appears to lie primarily in facilitating transitions of care and improving patient flow, rather than consistently improving outcomes when used as a substitute for ICU admission.

Tele-critical care support beyond the intensive care unit

Tele-critical care (TCC) has emerged as a key strategy to expand access to specialist expertise, optimize resource utilization, and support the management of critically ill patients beyond the physical boundaries of the ICU.¹⁰ By enabling remote intensivist-led consultation, real-time monitoring, and multidisciplinary coordination across EDs, general wards, and IC units, TCC contributes to earlier recognition of clinical deterioration and more timely decision-making, particularly in hospitals with limited onsite critical care resources.³⁷

Over time, TCC has evolved from a primarily observational telemedicine model into an integrated extension of the ICU, with increasing involvement in clinical decision-making, including guidance on organ support, resuscitation, and care coordination.³⁸ This transition reflects a broader shift toward distributed critical care delivery, in which expertise is mobilized across the hospital rather than confined to a single unit. Observational studies suggest that TCC implementation may improve adherence to evidence-based practices and reduce hospital length of stay, although its impact on patient-centered outcomes remains heterogeneous.³⁷

Beyond traditional ICU settings, TCC plays an important role in supporting rapid response systems (RRS) and emergency care. By assisting teams managing deteriorating ward patients or ED boarding cases, TCC may facilitate earlier intervention, improve triage decisions, and, in some cases, prevent ICU admission. Observational data indicate that delays in ICU transfer are associated with increased mortality, both in ward and ED populations,¹⁷,³⁹reinforcing the potential value of early specialist input. Integration of TCC into rapid response workflows has also been associated with reduced ICU transfer rates in selected settings.⁴⁰

Despite these potential benefits, TCC effectiveness depends heavily on system integration. Its value appears to be less related to technological sophistication and more to how effectively it is embedded within clinical workflows, response systems, and institutional governance. While centralized hubs and advanced monitoring infrastructure enable scalability, excessive emphasis on technical components may not translate into improved outcomes without coordinated implementation.⁴¹,⁴²

From a resource perspective, TCC requires substantial investment in infrastructure and staffing, which may limit its applicability in some settings.⁴³,⁴⁴ However, by extending specialist coverage without proportionally increasing onsite workforce, it offers a potentially scalable solution for hospitals facing fluctuating demand and workforce constraints.

In this context, TCC should be viewed not as a standalone intervention, but as part of a broader system-level strategy to enhance early detection, support clinical decision-making, and improve patient flow across the continuum of care. Its impact ultimately depends on alignment with local resources, clinical processes, and organizational priorities.

Hospital-based palliative care teams development

Palliative care is an interdisciplinary approach that integrates medical, nursing, and psychosocial support to improve quality of life for patients with serious illness and their families.⁴⁵ Beyond symptom control, it facilitates structured communication and shared decision-making, aligning treatment strategies with patient values and goals. Importantly, palliative care is considered a cost-effective intervention and should ideally be introduced early in the disease trajectory, alongside disease-directed therapies.⁴⁶

In the hospital setting, palliative care interventions may benefit both patients and health systems. Advance care planning - through proactive discussions about prognosis and treatment preferences - has been associated with reductions in ICU utilization and hospital length of stay. A systematic review reported a 37% relative reduction in ICU admissions among patients at high risk of death.⁴⁷ Early palliative involvement is particularly relevant in populations with limited life expectancy, such as advanced cancer or terminal dementia, when it has been associated with lower ICU use and reduced likelihood of in-hospital death.⁴⁸

Integration of palliative care into ICU practice, whether through consultation or embedded models, may further optimize resource utilization. Evidence suggests reductions in ICU and hospital length of stay without an increase in mortality,⁴⁹ with meta-analytic data indicating a relative reduction of approximately 26% in length of stay.⁴⁵ At the institutional level, hospital-based palliative care programs have been associated with modest but clinically meaningful reductions in ICU use during terminal hospitalizations.⁵⁰

Palliative care also plays an important role within RRS, where patients frequently face critical decisions regarding escalation or limitation of life-sustaining therapies. Incorporating palliative principles into these workflows enables timely goal-of-care discussions and symptom management, although effective implementation requires structured training and system-level support.⁵¹

From a systems perspective, palliative care should be viewed not as an end-of-life intervention, but as a core component of a broader strategy to improve care alignment, reduce non-beneficial ICU utilization, and support more efficient use of critical care resources without compromising patient-centered outcomes.

Development of automatic early warning systems for hospitalized patients

Clinical deterioration and unexpected adverse events occur in approximately 10% of hospital admissions, underscoring the importance of timely recognition and intervention.⁵² Abnormal vital signs often represent the earliest indicators of impending instability and form the basis for structured alerting strategies. These approaches generally include single-parameter trigger systems, aggregate Early Warning Scores (EWSs), and more advanced predictive models supported by electronic health records.¹¹

Early Warning Scores have been widely adopted to standardize the identification of clinical deterioration and facilitate escalation of care. However, patient heterogeneity and clinical context influence their performance, and fixed thresholds may not capture individual variability.¹¹ While widely used systems such as Modified Early Warning Score (MEWS) and National Early Warning Score (NEWS) have contributed to a shared framework for risk stratification, their incremental benefit over clinical judgment remains uncertain, particularly when not integrated with effective response systems.⁵²,⁵³

The expansion of electronic health records has enabled the development of more complex predictive models that incorporate large volumes of clinical data to support real-time decision-making.⁵²,⁵⁴Some systems have improved process-related outcomes, such as earlier antibiotic administration or increased detection of clinical deterioration, and in selected settings have been associated with reduced mortality.⁵⁴ However, these findings are not consistent across studies, and their generalizability remains uncertain.

A key challenge in designing alert systems is balancing sensitivity and specificity. Increasing sensitivity enhances early detection but may generate a high volume of alerts, contributing to alarm fatigue and reducing clinical effectiveness.¹¹ As a result, the value of these systems depends not only on predictive accuracy but also on their integration with clinical workflows and escalation pathways. Clinical judgment therefore remains essential, and mechanisms that incorporate clinician concern into activation criteria may improve performance.

Evidence regarding the overall impact of EWS implementation on patient-centered outcomes remains inconclusive. While some studies suggest modest improvements, systematic reviews and meta-analyses have reported heterogeneous results, with limited or no consistent effect on mortality, ICU admission, or length of stay.⁵⁵,⁵⁶ Methodological limitations and implementation variability likely contribute to these findings.

Within this framework, early warning systems should be viewed as enabling tools rather than definitive solutions, with effectiveness largely determined by how well they are integrated into RRS, staff training, and institutional capacity to act on alerts in a timely and consistent manner.

Rapid response systems implementation

Rapid response systems, also referred to as rapid response teams, were developed as hospital-based strategies to identify and manage clinical deterioration that might otherwise remain unrecognized in general wards. This model extends critical care expertise beyond the ICU, aiming to facilitate early intervention, optimize resource allocation, and improve patient safety.¹¹ In addition to supporting timely escalation of care, RRSs may contribute to more efficient patient flow and earlier transfer to appropriate levels of care.⁴²

Operationally, RRSs integrate early detection, structured escalation pathways, and specialized response teams capable of bedside assessment and stabilization. Although these systems are often described in terms of afferent and efferent components, their effectiveness depends less on structural definitions and more on reliable activation criteria, team responsiveness, and integration within institutional workflows.⁵⁷,⁵⁸

Despite widespread implementation, evidence regarding their impact on hard clinical outcomes remains heterogeneous. Variability in study design, patient populations, and implementation strategies has contributed to inconsistent findings, particularly for endpoints such as mortality and cardiac arrest.⁵⁹,⁶⁰Moreover, traditional outcome measures may not fully capture system-level benefits, including improved communication, earlier recognition of deterioration, and reinforcement of a hospital-wide safety culture.

Within this framework, CCOTs play a central role in bridging the gap between ICU and ward care. By supporting patients at risk of deterioration and those recently discharged from the ICU, these teams facilitate safer transitions, enhance staff education, and promote timely escalation when needed.⁶¹ Observational data suggest potential reductions in ICU readmissions and hospital mortality, although effects are context-dependent and influenced by local resources and organizational structure.⁶² In some settings, expanding access to patients and families has further strengthened early detection and responsiveness.⁴²,⁶³

Accordingly, RRSs should be considered dynamic components of a broader system-level strategy to improve early detection, care coordination, and continuity across hospital settings. Their impact is closely linked to implementation quality, staff engagement, and the institution’s ability to respond effectively to clinical deterioration once identified.

Optimize critical care resources in elective surgical patients

Surgical patients account for a substantial proportion of ICU admissions after elective, urgent, or emergency procedures.⁶⁴ Approximately 8 - 10% of patients undergoing major surgery require ICU admission, most often for postoperative monitoring and early management of complications.⁶⁵,⁶⁶ However, perioperative risk is dynamic and difficult to define using standardized admission criteria alone, as postoperative deterioration frequently depends on the interaction between procedural complexity, baseline comorbidities, and early postoperative evolution.⁶⁷,⁶⁸

Whether routine ICU admission improves outcomes in high-risk surgical patients remains uncertain. In resource-constrained settings, limited ICU availability may delay elective procedures, whereas indiscriminate ICU use may contribute to inefficient allocation of critical care resources.⁶⁹ Current recommendations therefore emphasize individualized triage based on patient risk, procedural complexity, and local capacity.⁶¹,⁷⁰ Several strategies have been proposed to optimize perioperative ICU bed allocation. In one study, 23% of surgical ICU days were considered potentially avoidable, with targeted interventions reducing this proportion to 15.3%.⁷¹ Proposed measures included implementation of procedure-specific admission criteria, optimization of postoperative airway management in collaboration with anesthesiology teams, improved communication before ICU transfer, and earlier identification of patients who may benefit from palliative care pathways.

As part of a broader hospital-wide strategy for ICU capacity management, alternative postoperative care pathways may help optimize resource utilization. Intermediate care units, post-anesthesia care units (PACU), and structured outreach models can provide enhanced monitoring for selected patients while reducing unnecessary ICU admissions.⁶⁷,⁶⁸,⁷² Some studies have reported that these approaches may preserve patient safety while improving postoperative flow and reducing ICU utilization, particularly when integrated with perioperative pathways such as Enhanced Recovery After Surgery (ERAS).⁶⁸,⁷² Accordingly, perioperative management should be viewed less as an isolated surgical issue and more as part of a coordinated system that flexibly allocates monitoring intensity according to evolving patient needs.

Open and closed intensive care unit models and their role in bed management

The organizational structure of the ICU - whether open or closed - can substantially influence bed utilization, patient flow, and overall resource efficiency. These models differ primarily in governance, responsibility for clinical decision-making, and coordination of care, all of which directly affect ICU capacity management.⁷³

In open ICU models, the primary admitting physician retains responsibility for patient management, while intensivists provide consultation as needed. Although this approach may preserve continuity with specialty teams, it can introduce variability in admission thresholds, escalation practices, and discharge timing, potentially leading to heterogeneous ICU utilization and prolonged length of stay.⁷³ Such variability may increase the likelihood of admitting patients who could be managed safely in lower-acuity settings, thereby limiting bed availability for more critically ill individuals.

In contrast, closed ICU models centralize clinical authority within an intensivist-led team, promoting standardized protocols, consistent triage decisions, and coordinated multidisciplinary care.⁷³ This structure may enhance operational efficiency by reducing unnecessary admissions, facilitating earlier transfer to step-down or ward-based care, and minimizing unwarranted variation in ICU length of stay.

Contextual factors, including intensivist availability, institutional culture, case mix, and regulatory constraints must guide the choice between organizational models. In resource-limited settings, fully closed models may not be feasible; however, standardized admission and discharge criteria, structured multidisciplinary rounds, and clear escalation pathways may mitigate variability and improve coordination within open systems.⁷⁴

Intensive care unit governance should therefore be understood as a key lever for optimizing critical care capacity. When aligned with complementary strategies - such as IC units, RRS, tele-critical care, and perioperative risk stratification - organizational models can support more efficient patient flow and reduce unnecessary ICU utilization.⁷⁵ Intensive care unit design, in this regard, extends beyond administrative structure and becomes a determinant of resource stewardship. Models that promote centralized oversight and coordinated decision-making are more likely to balance clinical quality with sustainable use of critical care resources.

Optimization of intensive care unit discharge processes and bed flow management

Although ICU capacity discussions often focus on admission control, discharge efficiency plays an equally decisive role in bed availability. The ‘ICU output bottleneck’ refers to delays in transferring clinically stable patients to lower levels of care. When ward beds, IC units, or step-down pathways are unavailable or poorly coordinated, patients who no longer require full intensive support remain in the ICU (Table 3). This downstream constraint restricts access for newly deteriorating patients and contributes to ED boarding, surgical delays, and inter-hospital transfer barriers.

Table 3
Potential benefits and challenges of the intensive care units without walls framework

Potential benefits	Challenges
Early identification of clinical deterioration through systematic surveillance	Ensuring adequate staffing levels across ICU and ward settings
Rapid expert guidance for ward staff managing unstable patients	Requirement for structured and continuous training programs
Timely escalation to ICU when clinically indicated	Risk of deskilling or over-reliance on outreach teams by ward clinicians
Improved continuity of care across transitions (ICU-ward-ED)	Need for clearly defined roles, responsibilities, and accountability
Inclusion of patients and families in shared decision-making processes	Dependence on strong interprofessional trust and communication culture
Knowledge sharing and interdisciplinary learning	Cultural resistance to changes in traditional hierarchical structures
Facilitation of earlier and safer ICU discharge	Requirement for reliable step-down capacity and monitoring systems
Enhanced post-ICU follow-up and reduction in readmissions	Financial investment in telemedicine, monitoring tools, and workforce expansion
Support for ward teams receiving complex ICU survivors	Standardization of ICU admission, discharge, and escalation criteria
Reduction in avoidable ICU admissions through early intervention	Risk of alert fatigue and over-escalation if early warning systems are poorly calibrated
Minimization of delays, duplication of tests, and inefficient resource use	Need for interoperable electronic health records and secure data sharing
Strengthening hospital-wide patient safety culture	Complexity of integrating multiple services (RRT, CCOT, TCC, IC units)
Opportunities for multidisciplinary research and quality improvement initiatives	Challenges in measuring performance and attributing outcome improvements
Improved surge capacity during crises (e.g., pandemics, disasters)	Sustainability concerns during prolonged high-demand periods
Greater organizational resilience and adaptability	Regulatory and medico-legal considerations across care boundaries

• ICU - intensive care unit; ED - Emergency Department; RRT - rapid response team; CCOT - critical care outreach team; TCC - tele-critical care; IC - intermediate care; EHR - electronic health record.

Intensive care unit discharge delays are multifactorial. Limited ward capacity, inadequate staffing outside the ICU, absence of IC units, and administrative barriers frequently prolong ICU stays.⁷⁶ Clinical uncertainty and concerns about readmission may further delay discharge decisions. In addition, insufficient integration of transitional care support - such as outreach teams - may discourage timely transfer if ward teams lack confidence in managing residual instability. Together, these factors reduce system responsiveness and constrain effective bed turnover.

Hospital strain further amplifies these challenges. High occupancy is often associated with earlier or off-hour discharges and greater variability in decision-making, potentially increasing the risk of communication gaps and fragmented care when handoffs are not adequately structured. Under these conditions, the tension between maintaining patient safety and freeing ICU capacity becomes particularly evident.

Accordingly, ICU bed shortages should be understood not only as a capacity limitation but also as a result of impaired patient flow. Expanding ICU beds without strengthening downstream infrastructure - such as IC units, structured discharge pathways, and coordinated transitional care models - is unlikely to resolve these constraints and may introduce additional inefficiencies.

Effective discharge optimization requires aligning admission practices with step-down capacity, supported by standardized criteria, clear communication processes, and institutional oversight. Integrating these elements within framework may enhance continuity of care, improve patient safety, and preserve ICU availability for those most in need. Ultimately, ICU capacity depends as much on the efficiency of patient exit pathways as on admission processes, underscoring the central role of discharge planning in sustainable critical care delivery.

FINAL COMMENTS

Intensive care unit capacity constraints reflect not only limited bed availability but also inefficiencies in patient flow, care transitions, and hospital organization. Because critical illness evolves along a continuum, fragmented care and frequent handoffs may delay interventions and cause communication failures. Accordingly, intensive care unit optimization strategies should be viewed as coordinated system-level interventions rather than isolated measures. The ideal model must integrate early recognition of deterioration, timely intervention, flexible care pathways, and structured governance. Approaches such as Emergency Department–based critical care, intermediate care units, tele-critical care, rapid response teams, and standardized triage and discharge processes shift the focus from simply expanding intensive care unit beds toward improving coordination and resource allocation. Implementation varies across healthcare systems. High-resource settings may depend on advanced technologies and dedicated infrastructure, whereas resource-constrained environments may rely on simplified protocols, workforce training, and optimization of existing capacity. Sustainable solutions therefore require system-level redesign adapted to local context.

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• ⁶⁹ Wong DJ, Harris SK, Moonesinghe SR; SNAP-2: EPICCS collaborators; Health Services Research Centre, National Institute of Academic Anaesthesia; Study Steering Group; Net Solving Limited; Trainee Research Networks; Abertawe Bro Morgannwg University Health Board; Aintree University Hospitals NHS Foundation Trust; Airedale NHS Foundation Trust; Aneurin Bevan Health Board; Ashford & St Peters NHS Foundation Trust; Barking, Havering and Redbridge University Hospitals NHS Trust; Barnsley Hospital NHS Foundation Trust; Barts Health NHS Trust; Basildon and Thurrock University Hospitals NHS Foundation Trust; Bedford Hospital NHS Trust; Belfast Health and Social Care Trust; Betsi Cadwaladr University Health Board; Birmingham Women’s NHS Foundation Trust; Blackpool Teaching Hospitals NHS Foundation Trust; Bolton Hospital NHS Foundation Trust; Bradford Teaching Hospitals NHS Foundation Trust; Brighton and Sussex University Hospitals NHS Trust; Buckinghamshire Healthcare NHS Trust; Burton Hospitals NHS Foundation Trust; 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Sandwell and West Birmingham Hospitals NHS Trust; Sheffield Teaching Hospitals NHS Foundation Trust; Shrewsbury and Telford Hospital NHS Trust; South Eastern Health and Social Care Trust; Southport and Ormskirk Hospital NHS Trust; South Tees Hospitals NHS Foundation Trust; South Tyneside NHS Foundation Trust; South Warwickshire NHS Foundation Trust; St George’s Healthcare NHS Trust; St Helens and Knowsley Teaching Hospitals NHS Trust; Stockport NHS Foundation Trust; Surrey and Sussex Healthcare NHS Trust; Tameside Hospital NHS Foundation Trust; Taunton and Somerset NHS Foundation Trust; Torbay and South Devon NHS Foundation Trust; United Lincolnshire Hospitals NHS Trust; University College London Hospitals NHS Foundation Trust; University Hospital of North Midlands NHS Trust; University Hospital of South Manchester NHS Foundation Trust; University Hospitals Birmingham NHS Foundation Trust; University Hospitals Bristol NHS Foundation Trust; University Hospitals Coventry and Warwickshire NHS Trust; University Hospitals of Leicester NHS Trust; University Hospitals of Morecambe Bay NHS Foundation Trust; University Hospital Southampton NHS Foundation Trust; Walsall Healthcare NHS Trust; Warrington & Halton Hospitals NHS Foundation Trust; Western Health and Social Care Trust; Western Sussex Hospitals NHS Foundation Trust; West Herts Hospitals NHS Trust; Weston Area Health NHS Trust; West Suffolk NHS Foundation Trust; Whittington Hospital NHS Trust; Wirral University Teaching Hospital NHS Foundation Trust; Worcestershire Acute Hospitals NHS Trust; Wrightington, Wigan and Leigh NHS Foundation Trust; Wye Valley NHS Trust; Yeovil District Hospital NHS Foundation Trust; York Teaching Hospital NHS Foundation Trust. 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Statement on the use of Artificial Intelligence

During the preparation of this manuscript, the authors used ChatGPT for review of grammatic and semantic of the words. After using this tool, the authors reviewed and edited the content and assume full responsibility for the content of the publication.

Corresponding author

: Cassiano Teixeira. Hospital Moinhos de Vento. Rua Ramiro Barcelos, 910. Zip code: 91340-001 - Porto Alegre (RS), Brazil. E-mail: [e-mail]

Conflicts of interest:

None.

Responsible editor:

Otávio Ranzani. https://orcid.org/0000-0002-4677-6862

Publication Dates

• Publication in this collection
  06 Nov 2026
• Date of issue
  2026

History

• Received
  3 Mar 2026
• Accepted
  4 June 2026