a recent report in critical care demonstrates the types of steps hospitals are taking to address the growing problem of icu capacity constraints . these steps are often necessary , as icu strain leads to serious , real - world problems . for example , both admission delays from the emergency department to the icu and premature discharges from the icu to the ward are associated with increased mortality . moreover , although the data are mixed , new evidence suggests that when icus are strained , patients in the icu experience a greater risk of death . cancelling high - risk elective surgeries due to a lack of appropriate postoperative care means less revenue at a time when many hospitals are struggling financially . clearly the stakes are high . when faced with icu capacity constraints , however , hospitals have a limited number of options . the first , and perhaps most obvious , option is to simply add more icu beds . hospitals are taking this approach in the united states , where the number of icu beds is increasing over time . however this approach is misguided at best and harmful at worst - hospitals vary in the degree to which they use intensive care without much variation in outcome , suggesting that many icu patients do not really benefit from icu - level care . additionally , increasing the number of icu beds increases the hospitals fixed costs while at the same time creating waste in the system during times when the icu is not full . another option is to create alternative levels of care within the hospital for moderate - risk patients who may not need the icu . these alternatives can take the form of step - down units for patients in recovery   or , as demonstrated by kastrup and colleagues , expanded post - anesthesia care units ( pacus ) that can care for intermediate risk , short - stay patients . the benefits of these approaches are that they increase icu capacity more efficiently than simply adding icu beds , since these types of beds are cheaper to maintain . as a case in point , in kastrup and colleagues ' study the hospital case mix index - a measure of hospital efficiency related to the average cost per case - increased from 0.286 to 0.309 , indicating a lower cost per case and , presumably , higher operating margins . at the same time , length of stay in the icu increased - probably due to both removal of short - stay postoperative patients from the denominator and a lack of bed pressure to discharge patients earlier in their treatment course . although at first glance this move appears to have been a good one for the hospital , it is worth noting several caveats that could cause efforts like these to backfire . first , increasing icu capacity by shuttling some postoperative patients through the pacu could just result in more low - risk patients being admitted from the ward . this effect would increase the cost of care for these patients , negating other cost savings . second , this move presupposes that an intensivist and trained icu nurses are available to staff the pacu . in many health systems , in addition to these caveats , kastrup and colleagues ' study has some noteworthy limitations . the case mix index is a crude measure of hospital efficiency , and actual costs , charges and margins are not reported . also , this was a single - center , before - after study that did not control for severity of illness . at least some of these changes are probably due to differences in severity of illness on admission and routine temporal trends , rather than due to the staffing change itself . despite these limitations , kastrup and colleagues ' study provides important lessons about the risks and rewards of expanding icu capacity . providing high - quality critical care in the era of capacity constraints requires creative solutions . adding more icu beds is conceptually easy but is also costly and inefficient . developing new service lines that can care for intermediate - risk patients is more efficient , but is only of value in some circumstances . for example , the high - intensity pacu approach of kastrup and colleagues will not work for icus with low numbers of postoperative patients or for icus that only care for extremely high - risk surgery patients that almost always require icu admission . finally , we must remember that much of icu utilization is overuse - many patients , especially those at very high risk of death , would not want intensive care at their end of life . addressing capacity constraints purely by adding capacity , rather than working to prevent overuse , may be a missed opportunity to better align care with patient preferences . otherwise we risk making changes that are purely about improving the bottom line , rather than about improving care for our patients .