Original Research

Journal of Intensive Care Medicine

1-13
The Impact of Opening a Medical ª The Author(s) 2018
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Step-Down Unit on Medically Critically Ill DOI: 10.1177/0885066618761810
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Patient Outcomes and Throughput:
A Difference-in-Differences Analysis

Hayley B. Gershengorn, MD, FCCM1,2 , Carri W. Chan, PhD3,

Yunchao Xu, BSc(Hons)4, Hanxi Sun, MA5, Ronni Levy, MD6,
Mor Armony, PhD4, and Michelle N. Gong, MD, MS2,7

Abstract
Objective: To understand the impact of adding a medical step-down unit (SDU) on patient outcomes and throughput in a
medical intensive care unit (ICU). Design: Retrospective cohort study. Setting: Two academic tertiary care hospitals within the
same health-care system. Patients: Adults admitted to the medical ICU at either the control or intervention hospital from
October 2013 to March 2014 (preintervention) and October 2014 to March 2015 (postintervention). Interventions: Opening a
4-bed medical SDU at the intervention hospital on April 1, 2014. Measurements and Main Results: Using standard summary
statistics, we compared patients across hospitals. Using a difference-in-differences approach, we quantified the association of
opening an SDU and outcomes (hospital mortality, hospital and ICU length of stay [LOS], and time to transfer to the ICU) after
adjustment for secular trends in patient case-mix and patient-level covariates which might impact outcome. We analyzed 500 (245
pre- and 255 postintervention) patients in the intervention hospital and 678 (323 pre- and 355 postintervention) in the control
hospital. Patients at the control hospital were younger (60.5-60.6 vs 64.0-65.4 years, P < .001) with a higher severity of acute
illness at the time of evaluation for ICU admission (Sequential Organ Failure Assessment score: 4.9-4.0 vs 3.9-3.9, P < .001). Using
the difference-in-differences methodology, we identified no association of hospital mortality (odds ratio [95% confidence interval]:
0.81 [0.42 to 1.55], P ¼ .52) or hospital LOS (% change [95% confidence interval]: 8.7% [28.6% to 11.2%], P ¼ .39) with
admission to the intervention hospital after SDU opening. The ICU LOS overall was not associated with admission to the
intervention hospital in the postintervention period (23.7% [47.9% to 0.5%], P ¼ .06); ICU LOS among survivors was sig-
nificantly reduced (27.5% [50.5% to 4.6%], P ¼ .019). Time to transfer to ICU was also significantly reduced (26.7%
[44.7% to 8.8%], P ¼ .004). Conclusions: Opening our medical SDU improved medical ICU throughput but did not affect
more patient-centered outcomes of hospital mortality and LOS.

Keywords
step-down units, intermediate care units, hospital units, intensive care units, critical care, hospital administration, hospital
mortality, length of stay

1
Division of Pulmonary, Allergy, Critical Care, and Sleep Medicine, University of Miami Miller School of Medicine, University of Miami and Jackson Memorial
Hospitals, Miami, FL, USA
2
Division of Critical Care Medicine, Albert Einstein College of Medicine, Montefiore Medical Center, Bronx, NY, USA
3
Division of Decision, Risk, and Operations, Columbia Business School, New York, NY, USA
4
Department of Information, Operations, and Management Sciences, New York University Stern School of Business, New York, NY, USA
5
Department of Statistics, Purdue University, West Lafayette, IN, USA
6
Division of Critical Care, New York Presbyterian Queens, Queens, NY, USA
7
Department of Epidemiology and Population Health, Albert Einstein College of Medicine, Montefiore Medical Center, Bronx, NY, USA

Received July 24, 2017. Received revised October 27, 2017. Accepted February 07, 2018.

Corresponding Author:
Hayley B. Gershengorn, University of Miami Miller School of Medicine, Rosenstiel Medical Science Building, 1600 NW 10th Avenue, Rm 7043B, Miami, FL
10461, USA.
Email: hbg20@med.miami.edu
2 Journal of Intensive Care Medicine XX(X)

Introduction SDU was added. The new medical SDU had telemetry,
frequent noninvasive blood pressure surveillance, and contin-
Step-down units (SDUs) are wards designed to provide care to
uous pulse oximetry and respiratory rate monitoring. No mon-
patients who are not ill enough to need the intensive care unit
itoring through invasive devices was available (eg, central
(ICU), but for whom general floor management is insufficient.
venous, invasive arterial, or intracranial pressure monitoring).
Despite the name, SDUs accommodate patients “stepping
Noninvasive positive pressure ventilation using a face mask
down” from the ICU, “stepping up” from general floor care,
and invasive positive pressure ventilation via a tracheostomy
coming directly from the operating room following surgery, or
tube were feasible.
being directly admitted from the emergency department
Both hospitals had a 14-bed medical ICU; the intervention
(ED).1-3 Because the number of patients per nurse is higher
hospital had an 18-bed mixed surgical/cardiothoracic/coronary
and monitoring requirements are lower than in the ICU,3,4 these
care ICU and the control hospital had one 12-bed surgical and
units are presumed to be a less costly alternative for appropriate
one 12-bed cardiothoracic ICU all governed by a unified
patients. Despite inconsistent data on the cost impact of
Division of Critical Care Medicine; both hospitals had
SDUs,5,6 SDUs are expanding both in the United States7 and
24-hour on-site board-certified intensivists. The medical ICU
globally.8
at the intervention hospital was staffed by a critical care fellow
While many studies have investigated the impact of intro-
and 2 critical care trained physician assistants (CCM-PAs)
ducing an SDU on hospital operations and patient outcomes,
during the daytime (7 AM-7 PM) and 1 CCM-PA overnight; at
the literature reaches no consensus regarding their effect. Pub-
the control hospital, the medical ICU was staffed by a critical
lished studies suggest the presence of an SDU results in less
care fellow and internal medicine house staff 24 hours/day. The
ICU use for low-risk patients,9-12 yet the impact of an SDU on
new medical SDU was part of a 12-bed combined medical–
patient flow through the hospital is less consistent.2,4,9,12-16
surgical SDU which was staffed from inception with 1 CCM-
Moreover, the impact of SDUs on mortality has been seen to
PA on-site 24 hours/day and 1 intensivist on-site during the
be highly variable.4,9,10,15,17-22
daytime with coverage as needed by a different on-site inten-
Some of this inconsistency likely results from the differen-
sivist primarily responsible for the surgical ICU overnight. The
tial impact of SDUs on different patient populations in different
nurse to patient ratio in the SDU was 1:4 (vs 1:2 in the ICU and
settings. Patient case-mix and local infrastructure (eg, support
1:8 on the general wards). The control hospital had a 12-bed
staff availability, monitoring capabilities on general wards)
surgical SDU (to which medical patients could not be admitted)
vary across hospitals.6,23 Consequently, SDUs will not be simi-
which was not altered throughout the study period.
larly impactful at all institutions. Some of the variability in
Two additional changes were made to the critical care ser-
published study results, however, may be due to study designs
vices at the control hospital during the study period. On
employed out of necessity. Randomized controlled trials are
December 15, 2013, a CCM-PA was added to the critical care
not practical when the intervention being investigated requires
outreach team (CCOT) which evaluates new potentially criti-
a large capital expenditure and irreversible construction. Thus,
cally ill patients outside the ICUs, suggests treatment options,
single-center, historically controlled (ie, pre- vs postinterven-
and determines triage; on July 1, 2014, a second critical care
tion) studies are common. Unfortunately, such approaches can-
fellow was added to the overnight medical critical care ser-
not control for unobservable temporal trends in patient severity
vices. No additional changes were made at the intervention
and outcomes.
hospital.
At Montefiore Medical Center, we had the unique experi-
ence of opening a medical SDU at 1 hospital in a health-care
system that includes a second similar hospital in which no SDU Study Time Line
was introduced. We used this opportunity to evaluate the
We defined the preintervention period as October 1, 2013, to
impact of the new SDU on hospital throughput and patient
March 31, 2014, and the postintervention period as October 1,
outcomes using the difference-in-differences methodology to
2014, to March 31, 2015. These periods were chosen to allow
account for secular trends. We hypothesized that introducing a
(1) a full 6 months of data in each time period to provide
medical SDU would result in shorter time to transfer to the ICU
adequate sample size, (2) a 6-month run-in after the medical
(TtTICU), shorter ICU and hospital length of stay (LOS), and
SDU opened on April 1, 2014, and (3) comparison of similar
lower hospital mortality (due to improved monitoring on ICU
months (given seasonal variability in medical critical illness
discharge for those going to the SDU) for medical ICU patients.
and staff aptitude).

Methods
We conducted a retrospective cohort analysis using data from 2
tertiary care hospitals at Montefiore Medical Center, an aca-
demic health-care system in the Bronx, New York. At the
intervention hospital, a closed 4-bed medical SDU was opened
on April 1, 2014 (Figure 1); at the control hospital, no medical
Cohort
We included patients admitted to the ICU after assessment by
our CCOT. All admissions to the medical ICU and SDU from
the wards, postprocedurely, or from the ED must be evaluated
and deemed appropriate for admission by this team. Outside
hospital transfers, which comprise a small proportion of
Gershengorn et al
Figure 1. Study time line. CC indicates critical care; PA, physician assistant.
admissions, are admitted directly to the ICU or SDU without
official CCOT evaluation and were excluded from our study
cohort. Immediate postoperative transfer to an ICU is usually
coordinated without CCOT consultation, although a minority
of postsurgical patients are evaluated by the CCOT; only those
seen by the CCOT were included, as the reason for CCOT
evaluation (which could not be reliably determined retrospec-
tively) in these patients is often “medical” (eg, sepsis).
Patients were included if all covariate and discharge data were
available; patients were excluded if (1) the consultation was
not the patient’s first CCOT evaluation of the hospitalization
(to allow for appropriate evaluation of hospital-based out-
comes such as LOS and mortality), (2) admission to the ICU
could not be confirmed, (3) they were transferred to the ICU
in a third hospital within the system, (4) they were admitted to
a nonmedical ICU, (5) the ICU admission resulting from the
consultation was not the first of the patient’s hospitalization,
or (6) TtTICU was >72 hours (out of concern for erroneous
time stamps).
Covariates and Outcomes
Available patient-level data included demographics—age, gen-
der, race, ethnicity, insurance, and chronic illness burden
(using Elixhauser comorbidity number24); details of acute ill-
ness—admitting diagnosis category, Laboratory-based Acute
Physiology Score25 at the time of hospital admission, whether
the patient was admitted to the hospital through the ED, and
Sequential Organ Failure Assessment (SOFA26) score at the
3
time of CCOT consultation; total ED LOS (for those patients
admitted via the ED); whether the patient was on the medicine
service; timing of hospital admission (weekend vs weekday);
and timing of CCOT consultation (month of year, weekend vs
weekday, and daytime vs overnight). Outcomes included hos-
pital mortality, hospital and ICU LOS, and TtTICU.
Statistical Analysis
Standard summary statistics were used to compare patients
admitted (1) pre- versus postintervention at each hospital
separately and (2) to the intervention versus control hospitals.
We performed a difference-in-differences analysis to evalu-
ate the impact of opening the SDU at the intervention hospi-
tal after adjustment for potential confounders. 27-30 This
methodology uses a multivariable regression modeling tech-
nique with an interaction term for “time period” (pre- vs
postintervention) and “hospital” (intervention vs control) to
allow assessment of the independent association of the inter-
vention with an outcome. The use of the control hospital
enables adjustment for unobservable temporal trends in
patient severity that might impact outcomes. Separate models
were constructed to evaluate the association of opening the
SDU and hospital mortality, hospital and ICU LOS, and
TtTICU; TtTICU and LOS were logarithmically transformed.
In addition to the inclusion of hospital, time period, and their
interaction term, all measured patient-level characteristics
were included as covariates.
4 Journal of Intensive Care Medicine XX(X)
Figure 2. Consort diagram. ICU indicates intensive care unit. *Excluding those transferred from an outside hospital directly into the medical
ICU.
Two assumptions are central to the difference-in-
difference technique: (1) temporal trends in outcomes for the
control and intervention hospitals were similar and (2) no
interventions other than that being studied occurred during
the study period to one hospital differently than to the other.
To test the first assumption, we used multivariable regression
modeling restricted to patients admitted during the preinter-
vention period; the model included the date of ICU admis-
sion, the “hospital” (control vs intervention), an interaction
term between the date of ICU admission and “hospital,” as
well as all other patient-level covariates. A nonsignificant
association of the date-hospital interaction term and outcome
in the preintervention period would indicate similar baseline
trends for that outcome. As aforementioned, 2 additional
changes were made at the control hospital. Due to this poten-
tial limitation of our approach, we also conducted a more
standard single-center, historically controlled (pre- vs post-
intervention) analysis at the intervention hospital as a robust-
ness check (see Appendix A).
Statistical analyses were performed using R 3.2.3 (The R
Foundation for Statistical Computing, Vienna, Austria). Insti-
tutional review board approval was obtained from Albert Ein-
stein College of Medicine (#2014-3190).
Results
Our primary cohort consisted of 500 (245 pre- and 255 post-
intervention) patients in the intervention and 678 (323 pre-
and 355 postintervention) patients in the control hospital
(Figure 2). Patients in the control hospital were younger
(60.5-60.6 vs 64.0-65.4 years, P < .001) with similar comor-
bidity burdens (Elixhauser number: 4.5-4.5 vs 4.5-5.0, P ¼
.15), but higher severity of acute illness at the time of CCOT
evaluation (SOFA: 4.9-4.0 vs 3.9-3.9, P < .001; Table 1). A
minority of patients in both hospitals were white (16.4%-
13.5% [control] vs 29.0%-31.0% [intervention], P < .001)
and a significant proportion were Hispanic or Latino
(43.0%-37.2% [control] vs 34.3%-28.2% [intervention],
P ¼ .004); Medicaid/Medicare was the primary insurer for
most patients in both hospitals (71.2%-54.1% [control] vs
62.0%-59.2% [intervention], Pcontrol ¼ .80). Fewer patients
were admitted to the hospital through the ED in the control
hospital (88.9%-82.5% vs 89.4%-90.6%, P ¼ .026), and those
from the ED had shorter ED LOS in the control hospital
(12.2-13.1 vs 13.6-14.1 hours, P ¼ .001). No difference was
seen between hospitals’ in-hospital mortality or hospital
LOS. The ICU LOS was shorter (3.4-2.9 vs 4.0-3.8 days,
 Table 1. Baseline Characteristics and Outcomes for Intensive Care Unit Patients.

Intervention Hospital Control Hospital Intervention vs Control Hospital

Characteristic Preintervention Postintervention P Value Preintervention Postintervention P Value P Value

# of patients 245 255 323 355

Age, years, mean (SD) 64.0 (18.4) 65.4 (16.8) .64 60.5 (16.5) 60.6 (16.5) .93 <.001
Male gender, % 46.9 45.1 .72 49.8 50.1 >.99 .18
Race, % .88 .51 <.001
White 29.0 31.0 16.4 13.5
Black 29.4 29.0 36.2 39.2
Other 41.6 40.0 47.4 47.3
Ethnicity, % .18 .26 .004
Hispanic/Latino 34.3 28.2 43.0 37.2
Non-Hispanic/Latino 58.8 60.8 52.0 54.9
Declined to answer 6.1 8.2 3.1 5.1
Unknown 0.8 2.7 1.9 2.8
Insurance, % .46 <.001 .80
Medicaid/Medicare 62.0 59.2 71.2 54.1
Private pay 37.6 40.8 28.5 45.6
Self-pay 0.4 0.0 0.3 0.3
Elixhauser comorbidities, mean (SD) 4.5 (2.3) 5.0 (2.3) .012 4.5 (2.3) 4.5 (2.2) .66 .15
Admitting diagnostic system, % .79 .30 <.001
Cardiovascular 4.5 5.1 6.2 5.4
Endocrine/Metabolic/Renal 9.8 7.1 11.5 7.9
Gastrointestinal 7.8 7.8 9.0 9.0
Gynecologic 1.2 2.4 0.0 0.0
Hematologic 1.2 1.6 2.2 2.3
Infectious Disease 46.9 53.3 40.6 39.2
Neurologic 10.2 8.2 9.6 14.4
Respiratory 12.7 11.0 11.1 11.8
Cancer/tumor 1.6 0.4 5.0 7.0
Other 1.2 0.8 2.2 2.3
Unknown 2.9 2.4 2.8 0.8
LAPS at hospital admission, mean (SD) 58.4 (32.3) 59.3 (35.4) >.99 61.3 (36.3) 53.1 (31.4) .005 .35
Admitted from the emergency department, % 89.4 90.6 .66 88.9 82.5 .022 .026
ED length of stay,a hours, mean (SD) 13.6 (10.7) 14.1 (11.0) .61 12.2 (9.8) 13.1 (12.5) .92 .001
Hospital admission on the weekend, % 25.3 23.1 .60 23.2 24.2 .79 .89
Medicine service,b % 99.18 99.22 >.99 98.45 90.7 <.001 <.001
SOFA at time of consultation, mean (SD) 3.9 (2.3) 3.9 (2.2) 0.91 4.9 (2.5) 4.0 (2.1) <.001 <.001
Month of critical care consultation, % 0.49 .45 .94
January 16.3 16.5 16.1 16.3
February 12.7 16.1 11.1 14.4
March 20.8 14.9 20.7 15.2
October 16.3 19.2 20.1 19.4
November 17.6 15.7 16.4 17.5
December 16.3 17.6 15.5 17.2
(continued)

5
6
Table 1. (continued)

Intervention Hospital Control Hospital Intervention vs Control Hospital

Characteristic Preintervention Postintervention P Value Preintervention Postintervention P Value P Value

Timing of critical care consultation, %

On a weekend 29.4 27.1 .62 28.2 27.3 .86 .90
During the daytime 50.6 50.6 >.99 56.4 51.8 .25 .26
Hospital mortality, % 20.4 21.2 .91 26.3 23.4 .42 .12
Hospital LOS, days, median (IQR)
All patients 11 (7-20) 12 (7-20) .59 12 (7-22.5) 12 (7-24) .65 .24
Hospital survivors 11 (7-19) 12 (7-20) .32 12 (7-19) 12 (7-23) .35 .25
Hospital nonsurvivors 14 (6-24.5) 12 (6.25-19) .49 13 (7-24) 13 (4-27.5) .59 .60
ICU LOS, days, median (IQR)
All patients 4.1 (1.9-8.9) 3.8 (1.8-7.9) .52 3.4 (1.8-6.7) 2.9 (1.6-7.0) .52 .002
ICU survivors 4.0 (2.0-8.9) 3.9 (1.9-7.8) .55 3.5 (1.8-6.7) 2.9 (1.7-6.2) .37 <.001
ICU nonsurvivors 4.4 (0.9-7.6) 3.5 (1.0-10.1) .89 3.0 (1.5-7.5) 3.2 (1.2-12.6) .75 .71
Time to transfer to the ICU, hours, median (IQR) 8.1 (5.2-12.3) 7.1 (4.4-11.9) .036 7.9 (4.9-15.2) 9.0 (5.2-18.4) .08 .017
Abbreviations: ED, emergency department; LAPS, laboratory-based acute physiology score; LOS, length of stay; ICU, intensive care unit; IQR, interquartile range; SD, standard deviation; SOFA, Sequential Organ
Failure Assessment.
a
Emergency department length of stay is calculated for all patients admitted from the emergency department.
b
Medicine service patients were defined as those on services from which admission to the medical ICU was more likely than admission to another ICU type after consultation by the critical care outreach team
than any other ICU; medicine patients included cardiology, otolaryngology, family medicine, gynecology, medicine, neurology, obstetrics, psychiatry, rehab medicine, and other; nonmedicine patients included
cardiothoracic surgery, general surgery, neurosurgery, orthopedic surgery, plastic surgery, urology, and vascular surgery.
Gershengorn et al
Figure 3. Association of being admitted to the intervention (as compared to the control) hospital in the postintervention period for ICU
patients. ICU indicates intensive care unit.
P ¼ .002) and TtTICU (7.9-9.0 vs 8.1-7.1 hours, P ¼ .017)
was longer in the control hospital.
Difference-in-Differences Analyses
Analysis of preintervention trends revealed no difference in
hospital mortality (odds ratio, OR [95% confidence interval,
CI]: 1.01 [0.997-1.02], P ¼ .20) associated with being at the
intervention versus control hospital (see Appendix B). Simi-
larly, there was no difference in the percentage change for
hospital LOS (0.2% [0.4% to 0.1%], P ¼ .20), ICU LOS
(0.1% [0.4% to 0.2%], P ¼ .50), and TtTICU (0.1% [0.3%
to 0.1%], P ¼ .51). These results support the first assumption
underlying difference-in-difference analyses—trends in out-
comes for the control and intervention hospitals were similar
preintervention.
Using the difference-in-differences methodology, we iden-
tified no association of hospital mortality (OR [95% CI]: 0.81
[0.42-1.55], P ¼ .52) or hospital LOS (% change [95% CI]:
8.7% [28.6% to 11.2%], P ¼ .39) with admission to
the intervention hospital during the postintervention period
(Figure 3; see Appendix C). The ICU LOS overall was not
associated with admission to the intervention hospital in the
postintervention period (23.7% [47.9% to 0.5%], P ¼ .06);
7
however, ICU LOS among survivors was significantly
reduced (27.5% [50.5% to 4.6%], P ¼ .019). Time to
transfer to the ICU was also significantly reduced (26.7%
[44.7% to 8.8%], P ¼ .04). In the standard pre- versus
postintervention analysis, similar improvements in measures
of ICU throughput were seen, but changes did not meet
statistical significance: ICU LOS for all patients (18.0%
[36.4% to 0.4%], P ¼ .06), ICU LOS of survivors
(16.0% [32.9% to 0.9%], P ¼ .06), and TtTICU (11.5%
[23.8% to 0.7%], P ¼ .07, see Appendix A).
Discussion
We found no impact on hospital mortality or LOS for medical
ICU patients associated with adding a medical SDU after
adjusting for secular trends in outcomes. The ICU LOS was
notably reduced by approximately one quarter for ICU survi-
vors, but no statistically significant difference was appre-
ciated when all ICU patients were considered. Time to
transfer to the ICU was also significantly reduced by approx-
imately one quarter. Together, these results suggest opening a
medical SDU can improve patient throughput but may not
alter more patient-centered outcomes of mortality and time
in the hospital.
8 Journal of Intensive Care Medicine XX(X)
Our finding that opening a medical SDU results in
improved patient throughput by reducing TtTICU for ICU
patients is novel. Mathews and Long used simulation to
demonstrate that converting all medical SDU beds to med-
ical ICU beds (capable of receiving both ICU and SDU
patients) at their tertiary care hospital would result in 14%
shorter TtTICU for all patients but 23% increases in admis-
sion delays for SDU-level patients.13 However, their study
does not provide insight into how maintaining ICU capacity
and adding an SDU would impact TtTICU. Opening an SDU
for surgical patients resulted in longer hospital LOS in 1
institution,14 while no impact was seen at another15; no
evaluation was made in either study, however, on the impact
of these units on ICU throughput.
Interestingly, we did not find an association of opening
our medical SDU with hospital mortality, despite finding
that adding the SDU was associated with a 26.7% reduction
in TtTICU which a number of studies have demonstrated is,
itself, associated with lower mortality.31-34 Several prior
studies found SDU presence reduced mortality,10,17-21 while
others found SDUs did not impact4,9,15 or even heightened22
mortality. The inconsistency of these results likely relates,
in part, to the heterogeneity of patient types (medical, sur-
gical, mixed, and single disease), hospital settings (aca-
demic and nonacademic), and countries studied. The
milieu into which an SDU is introduced will surely affect
its ability to have meaningful impact. Moreover, all studies
on this topic are likely limited by issues of study design.
First, in many of the published studies, a simple historically
controlled analysis was performed, and these results may be
strongly confounded by secular trends in outcomes. Second,
as in our study, sample size is often limited; thus, studies
such as ours may simply be underpowered to identify an
association which actually exists.
Our analysis suggests that ICU LOS for patients who
survive is reduced by 25.4% with the introduction of an
SDU. The ICU LOS was not reduced for all patients, as
nonsurvivors’ LOS was unchanged (a finding with face
validity as it would be difficult to understand how the avail-
ability of an SDU for post-ICU care would reduce ICU
nonsurvivors’ LOS); however, other interventions have been
shown to reduce ICU LOS for patients at high risk of ICU
mortality.35 ICU care is expensive, and while studies of
mixed medical and surgical ICU patients have found a
patient’s last day in the ICU costs less than his/her first,36,37
we previously demonstrated that for medical ICU patients
there is no drop in daily cost over the ICU stay.38 Even in
high occupancy ICUs, therefore, if opening an SDU contri-
butes to medical ICU LOS reductions without negatively
impacting hospital LOS or mortality, it may be cost-
effective.
Our study’s main strength stems from our ability to use a
control hospital to adjust for secular trends in outcomes—a
design not available to prior authors. Our study is limited by
a fairly small sample size (which may have left us underpow-
ered to detect a true difference in hospital mortality associated
with introducing an SDU, for example). Additionally, our study
is limited by deviations from one assumption on which the
difference-in-differences methodology is based: that no other
changes affected the hospitals differently during the study
period. While no additional changes were made at the inter-
vention hospital, staffing increased at the control hospital.
While we cannot know how these changes impacted patient
flow, we presume that more staffing would, if anything,
improve throughput (and outcomes) at the control hospital
(thus biasing our results toward the null). Given these limita-
tions, we conducted a standard pre-/postintervention analysis
for the intervention hospital in which we found, consistent with
the direction albeit not the significance of our primary analysis,
that overall and survivor ICU LOS and TtTICU were reduced
after adding the SDU.
Finally, we must acknowledge that our study is limited by its
retrospective nature; we cannot identify how or why adding the
SDU was associated with improved patient throughput. That
said, we conjecture that with an SDU, patients could be dis-
charged from the ICU sooner (in less stable conditions) than
were they to need to go to a general ward. As such, ICU LOS
for patients who survive decreased, thereby freeing limited ICU
beds earlier and enabling new patients to be transferred in faster
(reducing TtTICU).
Conclusions
Hospital organization is, by its nature, complex. No single
solution to any challenge is likely to be optimal for all settings.
And, while an intervention may positively impact certain
metrics, unintended potentially negative consequences may
result. Opening an SDU is like any other such initiative. Indeed,
theoretical models of SDUs suggest that “one size does not fit
all.”23 While we found a positive association with opening a
medical SDU and medical ICU patient throughput (namely
TtTICU and ICU LOS for survivors), it is hard to know how
generalizable this finding is. What we do know, however, is
that in some circumstances, such improvements can be seen
with this intervention. Thus, it is appropriate to consider open-
ing an SDU if delays in ICU throughput are a major problem at
a given institution, especially as we found no negative impact
on patient outcomes.
Appendix A
Standard Historically Controlled Analysis
Due to the potential limitations—due to violation of one of
the underlying assumptions—of our difference-in-
differences approach, we conducted a more standard
single-center, historically controlled (ie, pre- vs postinter-
vention) analysis as a robustness check. To do so, we cre-
ated standard multivariable regression models for the
intervention hospital and, separately, the control hospital
to identify factors associated with each of our 4 out-
comes—hospital mortality, hospital and ICU LOS, and
TtTICU. In each case, we included a binary variable for
Gershengorn et al 9

pre- versus postintervention as well as independent covari- After multivariate adjustment, the odds of hospital mortality,
ates for all available patient-level factors. The outcomes of hospital LOS, ICU LOS, and TtTICU were not statistically dif-
TtTICU and LOS were logarithmically transformed as in the ferent in the post- versus the preintervention period at either the
primary difference-in-differences analysis. intervention (Figure A1) or the control (Figure A2) hospital.

Figure A1. Association of being in the postintervention period on outcomes at the intervention hospital. ICU indicates intensive care unit.
10 Journal of Intensive Care Medicine XX(X)

Figure A2. Association of being in the postintervention period on outcomes at the control hospital. ICU indicates intensive care unit.

Appendix B

Table B1. Test of Assumption 1 for the Difference-in-Differences Model—The Association Between Hospital (Intervention vs Control)
Admission and Date of Admission in the Preintervention Period.

Odds Ratio (95% CI) Percentage Change (95% CI) P Value

Hospital mortality 1.006 (0.997 to 1.015) .202

Hospital length of stay
All patients 0.2 (0.4 to 0.1) .201
Hospital survivors 0 (0.3 to 0.2) .792
Hospital nonsurvivors 0.6 (1.4 to 0.2) .156
ICU length of stay
All patients 0.1 (0.4 to 0.2) .502
ICU survivors 0 (0.3 to 0.3) .869
ICU nonsurvivors 0.3 (1.9 to 1.4) .757
Time-to-transfer to the ICU 0.1 (0.3 to 0.1) .511
Abbreviations: CI, confidence interval; ICU, intensive care unit.
 Appendix C

Table C1. Adjusted Association of Covariates With Outcomes for ICU Patients (Difference-in-Difference Analysis).
Hospital LOS ICU LOS
Hospital Time to Transfer
Mortality All Patients Hospital Survivor Hospital Expired All Patients ICU Survived ICU Expired
Odds Ratio
Covariatesa (95% CI) % Change (95% CI) % Change (95% CI) % Change (95% CI) % Change (95% CI) % Change (95% CI) % Change (95% CI) % Change (95% CI)

Intervention hospital 0.71 (0.44 to 1.14) 8.7 (23.2 to 5.7) 3.5 (17.6 to 10.5) 31.5 (71.4 to 8.4) 16.9 (0.7 to 34.5) 24.7 (8.0 to 41.3) 55.5 (140.9 to 30.0) 5.0 (18.1 to 8.0)
Postintervention period 1.22 (0.79 to 1.87) 1.0 (12.3 to 14.4) 9.9 (3.3 to 23.1) 33.0 (67.6 to 1.7) 7.9 (8.3 to 24.2) 12.5 (3.2 to 28.1) 11.7 (79.4 to 55.9) 12.1 (0.1 to 24.2)
Intervention hospital  0.81 (0.42 to 1.55) 8.7 (28.6 to 11.2) 14.5 (33.8 to 4.8) 23.9 (30.2 to 78.0) 23.7 (47.9 to 0.5) 27.5 (50.5 to 4.6) 22.7 (88.1 to 133.5) 26.7 (44.7 to 8.8)
postintervention period
Age 1.04 (1.02 to 1.05) 0.2 (0.5 to 0.1) 0.1 (0.2 to 0.4) 0.8 (1.8 to 0.1) 0.2 (0.6 to 0.2) 0.0 (0.4 to 0.4) 1.0 (3.1 to 1.0) 0.0 (0.3 to 0.3)
Male gender 1.08 (0.78 to 1.48) 3.6 (6.3 to 13.5) 2.9 (12.7 to 6.8) 23.4 (3.2 to 50.0) 4.1 (8.0 to 16.1) 0.6 (10.9 to 12.1) 31.1 (24.6 to 86.8) 12.1 (3.2 to 21.0)
Race: other 1.22 (0.69 to 2.16) 6.3 (10.5 to 23.2) 3.1 (13.4 to 19.5) 14.3 (31.8 to 60.4) 21.7 (1.1 to 42.2) 17.1 (2.2 to 36.5) 3.3 (101.8 to 95.3) 8.8 (24.0 to 6.4)
Race: white 1.68 (1.07 to 2.64) 4.4 (9.9 to 18.6) 11.5 (2.7 to 25.6) 9.7 (47.8 to 28.3) 20.0 (2.6 to 37.3) 24.8 (8.0 to 41.5) 3.7 (73.2 to 80.6) 9.8 (22.7 to 3.0)
Ethnicity: Hispanic/Latino 1.09 (0.48 to 2.48) 7.9 (31.9 to 16.1) 8.7 (31.7 to 14.3) 37.5 (108.5 to 33.5) 6.8 (36.1 to 22.4) 12.8 (40.0 to 14.5) 51.8 (106.6 to 210.2) 5.6 (16.0 to 27.3)
Ethnicity: not Hispanic/Latino 1.24 (0.58 to 2.67) 2.9 (19.7 to 25.5) 1.5 (23.7 to 20.6) 7.8 (69.5 to 53.9) 15.7 (11.8 to 43.2) 4.9 (21.2 to 31.0) 58.9 (70.0 to 187.8) 2.6 (17.8 to 23.0)
Ethnicity: unavailable 1.07 (0.25 to 4.65) 29.5 (69.5 to 10.5) 33.9 (71.4 to 3.7) 107.1 (246.9 to 32.6) 62.7 (111.4 to 14.1) 86.5 (132.3 to 40.7) 65.4 (205.2 to 336.1) 14.1 (50.1 to 22.0)
Admitting Dx: cancer/tumor 2.03 (0.50 to 8.27) 9.1 (32.8 to 51.0) 2.4 (43.8 to 39.0) 70.3 (54.1 to 194.6) 19.4 (70.3 to 31.6) 42.8 (92.1 to 6.6) 112.8 (115.2 to 340.9) 67.2 (104.9 to 29.4)
Admitting Dx: cardiovascular 0.25 (0.06 to 1.04) 22.5 (17.6 to 62.6) 10.9 (26.6 to 48.4) 48.6 (89.2 to 186.3) 20.1 (68.9 to 28.7) 25.1 (71.1 to 20.9) 26.9 (302.4 to 248.6) 49.2 (85.4 to 13.0)
Admitting Dx: Endo/Metab/Renal 0.11 (0.03 to 0.52) 9.0 (46.6 to 28.5) 31.5 (66.5 to 3.4) 112.7 (32.8 to 258.1) 23.8 (69.5 to 21.9) 39.0 (82.2 to 4.2) 86.3 (199.5 to 372.1) 52.7 (86.5 to 18.8)
Admitting Dx: gastrointestinal 0.37 (0.09 to 1.44) 16.3 (54.1 to 21.6) 28.9 (64.2 to 6.4) 32.6 (97.4 to 162.5) 47.7 (93.7 to 1.6) 66.0 (109.5 to 22.5) 126.5 (123.2 to 376.2) 71.1 (105.3 to 37.0)
Admitting Dx: gynecologic 0.00 (0.00 to Inf) 1.7 (64.8 to 68.2) 14.3 (73.1 to 44.4) omitted 34.2 (115.1 to 46.7) 51.5 (125.0 to 22.1) omitted 48.9 (108.8 to 11.1)
Admitting Dx: hematologic 0.55 (0.10 to 3.10) 42.9 (6.6 to 92.4) 25.8 (21.0 to 72.6) 96.9 (63.4 to 257.1) 18.3 (42.0 to 78.5) 9.5 (48.0 to 67.0) 120.4 (169.3 to 410.1) 49.5 (94.2 to 4.9)
Admitting Dx: infectious disease 0.58 (0.17 to 2.04) 31.5 (3.6 to 66.6) 13.2 (19.8 to 46.3) 89.5 (29.9 to 209.0) 6.6 (36.1 to 49.4) 13.2 (53.7 to 27.4) 150.8 (79.1 to 380.6) 34.5 (66.2 to 2.8)
Admitting Dx: neurologic 0.73 (0.19 to 2.73) 9.3 (46.5 to 27.8) 17.7 (52.4 to 16.9) 36.1 (90.9 to 163.2) 37.3 (82.5 to 7.8) 53.3 (95.9 to 10.8) 117.8 (135.1 to 370.7) 35.3 (68.8 to 1.8)
Admitting Dx: other 1.06 (0.19 to 5.85) 9.3 (40.9 to 59.5) 15.0 (62.8 to 32.8) 68.9 (86.5 to 224.3) 17.6 (78.7 to 43.5) 40.0 (97.9 to 17.8) 130.1 (169.9 to 430.1) 64.7 (109.9 to 19.4)
Admitting Dx: respiratory 0.28 (0.07 to 1.06) 12.0 (48.7 to 24.7) 36.2 (70.4 to 2.1) 53.7 (73.0 to 180.5) 17.9 (62.6 to 26.7) 38.1 (80.3 to 4.0) 67.1 (181.9 to 316.0) 37.0 (70.1 to 4.0)
Admitted from emergency 1.95 (1.01 to 3.75) 19.3 (36.9 to 1.7) 4.2 (20.8 to 12.3) 78.4 (147.8 to 9.0) 4.7 (16.7 to 26.1) 19.7 (0.3 to 39.6) 67.0 (214.4 to 80.4) 43.0 (58.8 to 27.1)
department
ED length of stay 1.02 (1.01 to 1.04) 0.7 (0.1 to 1.2) 0.4 (0.1 to 1.0) 1.3 (0.1 to 2.5) 0.7 (0.1 to 1.4) 0.3 (0.3 to 0.9) 3.0 (0.3 to 5.6) 3.4 (3.0 to 3.9)
CC consultation month: February 0.96 (0.53 to 1.73) 4.8 (13.2 to 22.8) 11.3 (6.2 to 28.8) 13.1 (61.9 to 35.8) 13.6 (35.5 to 8.2) 14.4 (35.2 to 6.5) 22.1 (77.2 to 121.3) 10.7 (5.5 to 26.9)
CC consultation month: March 1.03 (0.60 to 1.79) 12.2 (29.1 to 4.6) 10.3 (26.9 to 6.2) 16.2 (61.2 to 28.8) 28.4 (48.9 to 7.9) 29.9 (49.5 to 10.3) 3.7 (94.4 to 87.0) 13.1 (28.4 to 2.1)
CC consultation month: October 1.45 (0.83 to 2.53) 1.2 (15.7 to 18.1) 1.9 (14.4 to 18.3) 0.5 (48.2 to 47.1) 7.0 (27.5,13.5) 13.1 (32.5 to 6.4) 24.8 (67.8 to 117.3) 12.3 (27.5 to 2.9)
CC consultation month: November 0.93 (0.52 to 1.67) 5.0 (22.3 to 12.3) 0.3 (16.2 to 16.9) 35.0 (85.3 to 15.4) 8.2 (29.3 to 12.8) 4.5 (24.4 to 15.4) 25.3 (121.7 to 71.0) 6.0 (21.6 to 9.6)
CC consultation month: December 1.47 (0.84 to 2.57) 2.0 (19.2 to 15.2) 0.4 (16.6 to 17.4) 0.0 (44.4 to 44.4) 12.9 (33.8 to 8.0) 11.3 (31.1 to 8.5) 48.8 (144.5 to 46.9) 5.2 (10.3 to 20.7)
Weekend CC consultation 0.96 (0.60 to 1.53) 6.7 (7.7 to 21.1) 12.0 (2.2 to 26.2) 17.7 (56.7 to 21.3) 2.4 (19.9 to 15.1) 0.7 (17.3 to 15.9) 16.1 (98.8 to 66.6) 4.1 (17.1 to 8.8)
Weekend hospital admission 1.19 (0.73 to 1.93) 5.0 (20.1 to 10.2) 13.3 (28.3 to 1.7) 20.3 (20.1 to 60.7) 7.8 (10.6 to 26.2) 3.6 (13.8 to 20.9) 24.7 (65.7 to 115.1) 7.3 (20.9 to 6.4)
Daytime CC consultation 1.17 (0.85 to 1.62) 2.0 (11.8 to 7.8) 0.1 (9.6 to 9.4) 0.6 (27.5 to 26.3) 0.1 (12.0 to 11.9) 1.2 (12.5 to 10.1) 23.6 (33.7 to 81.0) 8.8 (0.0 to 17.7)
Insurance: private pay 0.84 (0.59 to 1.18) 4.4 (14.7 to 5.9) 3.5 (13.6 to 6.5) 9.2 (26.3 to 29.0) 8.4 (20.9 to 4.1) 8.6 (20.5 to 3.4) 21.3 (39.0 to 81.6) 1.7 (10.9 to 7.6)
Insurance: self-pay 0.00 (0.00 to Inf) 48.3 (144.9 to 48.4) 41.1 (124.0 to 41.8) omitted 76.3 (193.9 to 41.3) 71.3 (176.1 to 33.6) omitted 15.9 (103.1 to 71.3)
Admitting service: medicineb 0.87 (0.31 to 2.47) 18.0 (10.3 to 46.3) 12.4 (14.8 to 39.5) 23.1 (63.8 to 110.1) 25.6 (8.9 to 60.0) 28.3 (5.3 to 61.9) 42.0 (181.9 to 97.9) 62.0 (36.5 to 87.5)
Elixhauser comorbidities 1.14 (1.06 to 1.23) 12.2 (9.7 to 14.6) 9.5 (7.0 to 12.0) 14.0 (7.8 to 20.2) 8.5 (5.5 to 11.5) 6.8 (3.9 to 9.6) 13.7 (0.2 to 27.6) 1.3 (0.9 to 3.5)
SOFA at time of consultation 1.40 (1.29 to 1.52) 0.7 (1.9 to 3.3) 7.1 (4.3 to 9.9) 8.6 (14.7 to 2.4) 0.3 (3.4 to 2.9) 6.4 (3.1 to 9.6) 18.7 (30.9 to 6.5) 1.4 (3.8 to 0.9)
LAPS at admission 1.01 (1.00 to 1.01) 0.3 (0.5 to 0.1) 0.0 (0.2 to 0.1) 0.8 (1.2 to 0.4) 0.3 (0.0 to 0.5) 0.3 (0.1 to 0.5) 0.3 (0.5 to 1.1) 0.2 (0.0 to 0.4)

Abbreviations: CC, critical care; Dx, diagnosis; CI, confidence interval; ED, emergency department; ICU, intensive care unit; LAPS, Laboratory-Based Acute Physiology Score; LOS, length of stay; SOFA, Sequential Organ Failure Assessment.
a
Reference categories: black race, declined to answer ethnicity, known admitting diagnosis, critical care consultation in the month of January, and Medicaid/Medicare insurance.
b
Medicine service patients were defined as those on services from which admission to the medical ICU was more likely than admission to another ICU type after consultation by the critical care outreach team than any other ICU; medicine patients
included cardiology, otolaryngology, family medicine, gynecology, medicine, neurology, obstetrics, psychiatry, rehab medicine, and other; nonmedicine patients included cardiothoracic surgery, general surgery, neurosurgery, orthopedic surgery, plastic
surgery, urology, and vascular surgery

11
12
Authors’ Note
This work was performed at Albert Einstein College of Medicine,
Montefiore Medical Center.
Declaration of Conflicting Interests
The author(s) declared no potential conflicts of interest with respect to
the research, authorship, and/or publication of this article.
Funding
The author(s) disclosed receipt of the following financial support for
the research, authorship, and/or publication of this article: Carri W.
Chan is partially supported by NSF CMMI grant 1233547. Michelle
N. Gong is partially supported by NHLBI UH2 HL125119 and U01
HL122998.
ORCID iD
Hayley B. Gershengorn, MD, FCCM http://orcid.org/0000-0002-
7360-2489
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