The intermediate CCU admission: a preliminary study

In the current health care era, increasing emphasis is being placed on cost reduction. Admitting only high-risk patients to coronary care units (CCU) may reduce hospital costs and charges without adverse clinical outcomes. Recently, guidelines published by the Agency for Healthcare Policy and Research (AHCPR) on suggest that intermediate-risk patients be admitted to an intermediate CCU (ICCU), but the safety and appropriateness of this approach has not been prospectively evaluated. The authors hypothesized that admitting intermediate-risk patients with to an ICCU would be cheaper than admitting to a CCU with comparable safety supporting AHCPR guidelines. To evaluate this, a retrospective cohort study was conducted. Two hundred forty-three intermediate-risk patients consecutively admitted to the CCU (n = 134) and admitted to the ICCU (n = 109) between June 1, 1992 and April 1, 1994 were compared using AHCPR definitions of intermediate risk and a previously published risk prediction model to exclude both very low- and high-risk patients. Extensive demographic, clinical, and diagnostic testing, and treatment, procedural, and outcome data were collected by a trained nurse data collector at the time of admission. Fifty-nine percent of all study patients had at least two coronary risk factors. Twenty-one percent had diabetes. Ninety-eight percent had at least one AHCPR intermediate risk factor for cardiac complications. The two groups (CCU versus ICCU) were quite similar in baseline characteristics: men (56 versus 55%), age (57 +/- 17 versus 60 +/- 17 years), diabetes (22 versus 20%), previous myocardial infarction (30 versus 36%), previous coronary artery surgery (21 versus 21%), and rest pain (78 versus 66%). The use of coronary angiography (44 versus 52%), angioplasty (24 versus 21%), and coronary artery surgery (13 versus 11%) were also similar. The incidence of myocardial infarction or death was similar (3 versus 5%), and length of stay was also similar between groups (6.7 +/- 4.2 versus 6.5 +/- 4.1 days), but cost was less for patients admitted to the ICCU ($13,481 +/- 9,450 versus $10,619 +/- 8,732, P < 0.015). These preliminary data suggest intermediate-risk patients, as identified by AHCPR guidelines, can be treated in an ICCU at lower cost than in a CCU, with reasonable safety. A small incidence of myocardial infarction in ICCU-admitted patients occurs, requiring availability of cardiac resuscitation and continued monitoring of electrocardiographic and enzymatic abnormalities. Admission to ICCU poses no barrier to recommended patient evaluation and management.