Intensive Care Unit Organization, Management, and Value

Chapter 87 Intensive Care Unit Organization, Management, and Value



Daniel Yagoda, MPH , Ulrich H. Schmidt, MD, PhD , J. Perren Cobb, MD




1 How should intensive care units (ICUs) be organized?


Patient outcomes are best in units that provide care by multidisciplinary teams, including intensivists (physician ICU experts), nurses, respiratory and physical therapists, and clinical pharmacists and nutritionists. Our experience is that optimal team performance is critically dependent on open communication across disciplines, demonstrating respect and a willingness to listen to all. Experienced team leaders (typically provided by an intensivist director partnering with a nursing director) are required to create and maintain this environment while optimizing resource utilization. Important aspects of medical director involvement include bed triage, monitoring the system to ensure patient safety, and creation of a safety culture that promotes best practice. Several studies have shown decreased rates of complications and death and better resource utilization in units where patient care is managed primarily by ICU teams (closed ICUs). This may be due to better care for the critically ill provided by intensivist-led multidisciplinary teams and better coordination and fewer communication errors in closed units. Critical care educational programs should incorporate a management training component that addresses each of these issues.


Hospitals with more than one ICU typically create an infrastructure that promotes better communication, usually in the form of a critical care committee. These committees are composed of ICU medical directors, nursing directors, and representatives from hospital administration, clinical pharmacy, respiratory therapy, physical therapy, and clinical nutrition, all of whom participate in the care of critically ill patients. The critical care committee often provides the necessary venue for multidisciplinary, open dialog to identify threats to patient safety and quality care. The committee also creates a mechanism to improve operations, including creation of guidelines and protocols to decrease unwanted variation in ICU clinical practice. The authority and responsibilities of these committees varies significantly across hospitals: many simply provide a convenient monthly venue to improve communication, whereas others are authorized and funded to plan strategically on behalf of the hospital.


In our largest hospitals with multiple ICUs (e.g., academic medical centers), efficiency and cost pressures motivate evolution of the critical care committee to a hospital-based, center-type infrastructure. Center status within the hospital organization provides the opportunity to support a more robust and mission-specific governance across all ICUs, including standing committees for critical care clinical operations, patient safety, education, research, and outreach. The operational assumption for center leadership is that the center, on behalf of the hospital, has the authority to override directors of individual ICUs when the consensus is that patient safety and quality are at risk. A center without the appropriate level of authority may be ineffective at strategic planning and leading change that best serve the community (for example, lack of ICU care coordination and patient flow can increase waiting times in the emergency department and postanesthesia care units). In addition, resources are typically allocated better with this model, as it is much more efficient to redesign care and patient flow, establish informatics platforms, adhere to care protocols, and buy equipment working collaboratively across ICUs.



2 What is the Leapfrog Group, and how has it affected ICU models of care?


The Leapfrog Group was created in 1998 by a large group of employers to leverage purchasing power to improve the quality and affordability of health care. The initial focus was on reducing preventable medical errors in hospitals. On the basis of available evidence, the group concluded that the quality of ICU care is particularly important in avoiding errors and improving outcomes in hospitalized patients. Subsequent Leapfrog Group recommendations included an ICU physician staffing standard:



image Intensivists are present during daytime hours and provide clinical care exclusively in the ICU.


image When not present on site or via telemedicine, intensivists return pages within 5 minutes and arrange for a qualified practitioner to reach ICU patients within 5 minutes.


The relative mortality reductions of 15% to 60% seen with this model are substantial. The mechanism for better outcomes is not well understood but appears to be related to multidisciplinary, team-based care led by intensivists. These recommendations motivated significant changes in intensivist staffing, because Leapfrog purchasers (businesses) collectively exert considerable influence over hospitals and their payers to staff ICUs appropriately. Nevertheless, in 2010, only 34% of hospitals responding to the national Leapfrog survey were fully compliant with this standard. Widespread adoption of the intensivist model is constrained by the limited number of intensivists, higher personnel costs, and perceived threats to physician autonomy.



3 What can be done to address the shortage of intensivists and critical care nurses in the United States: Regionalization and telemedicine?


Despite the overwhelming evidence that intensivist-led, team-based ICU care improves outcomes and decreases costs, only 50% of critically ill or injured patients, at most, have access to high-intensity intensivist staffing in the United States. This supply–demand inequity will continue, especially in underresourced areas, because of the high costs of intensivist staffing and a growing, nationwide shortage of intensivists.


Similarly, a nationwide shortage of critical care nurses threatens optimal outcomes. The traditional ratio of nurse to patients in an ICU for adults is 1:2 or 1:1 depending on disease severity. Excess mortality has been noted with nurse-to-patient ratios of 1:3 or greater. According to 2010 data from the American Association of Critical Care Nurses, approximately 40% of critical care nurses are aged 50 years or above. As this older cohort retires from practice, the available supply of ICU nurses will be insufficient. These staffing problems will be exacerbated by the aging of the baby boomers and the associated increased demand for intensive care. Therefore other organizational approaches will be required to optimize outcomes, in addition to efforts to grow the clinical workforce.


Increasing the availability of advanced nurse educational programs, such as those that train acute care nurse practitioners, is one solution. Regionalization of ICU care is another option, matching ICU patient needs to available resources, classifying providing institutions as level 1, 2, or 3 on the basis of the availability of procedural expertise and the intensity of ICU physician staffing.


A second, complementary approach leverages advances in telemedicine and systems engineering, using real-time data exchange, advanced informatics, and videoconferencing to optimize interactions among patients, caregivers, and families across the street or across great distances. Engineering health by optimizing use of regionalization and telemedicine promises to effectively extend the positive impact of intensivist-led, team-based care, the limits of which have not been established.

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Jul 6, 2016 | Posted by in CRITICAL CARE | Comments Off on Intensive Care Unit Organization, Management, and Value

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