LAUSR

The business of medicine is governed by economic principles balancing supply and demand. What are the implications when something intrinsically valuable, such as health care, is a part of the equation? How does a consumer or a researcher define the economic value of an intervention? department (ED), assessment, stabilization, determination of critical care needs, an admission bed order, and then a wait for an intensive care unit (ICU) bed to become available (termed boarding ), which can take hours or even days. Causes of boarding are multifactorial; patients with higher-acuity illness,increasedlengthofhospitalstays,diminishedICUbedavailability,andmedicalstaffshortages have shifted the supply-to-demand ratio to the demand side. 1 Emergency department volumes continue to increase daily as patients lose access to primary care. 2 Boarding of critically ill patients in the ED is problematic on many levels. 3 The practice leads to delayed diagnosis, increased complications, increased mortality, and increased length of hospital stay. In addition to creating economic challenges and complex administrative problems, boarding has a negative impact on the wellness of clinicians and nurses, as well as patient-centered health care goals. 4 Prior work has assessed (among other solutions to this problem) bridging the default pathway with the implementation of an ED-ICU domain. 4 This approach facilitates the provision of critical care services for the patient while still in the ED and is a clinically viable solution for some health care systems. 4 The opened ED-ICU as a solution for critical care boarding 2015. Prior publications have delineated the efforts of this work and the associated benefits for patients. 4 In JAMA Network Open , Bassin et al 5 have addressed the economic implications of this model of care. Through a retrospective study from the perspective of quality per unit cost, the investigators focused on the denominator of this equation and evaluated direct costs incurred by the institution to deliver patient care. They studied the inflation-adjusted change in mean direct cost of care for patients before and after the implementation of a 9-bed ED-ICU with care provided by an emergency medicine (EM)–led team. Patients admitted to this unit would have otherwise undergone ED boarding and then likely admission to an inpatient ICU. Their findings demonstrated that despite a higher degree of acuity of illness and increased cost of care delivery, implementation of an ED-ICU was cost neutral for medical care delivered across their institution’s total ED population. The economics of this model are multifaceted and perspective dependent. Clinicians, payers, patients, other patients, and overall health care systems each value the ED-ICU differently. In determining systems of justice, the philosopher John Rawls suggested that we