Meghan B. Lane-Fall, Linda Hoke and Cheryl Maguire

What Is Collaborative Practice in the Intensive Care Unit?

Intensive care traces its origins to the mid-20th century, when acutely ill patients such as battlefield soldiers, patients with polio-associated respiratory failure, postsurgical patients, and premature infants were cared for in designated units. One of the factors distinguishing these early intensive care units (ICUs) from other units was the nurse-to-patient ratio. It was recognized very early that sicker patients required greater attention by all members of the ICU care team. Early practitioners of critical care thus appreciated the value of both nurses and physicians in the care of the critically ill patient.

The contemporary practice of intensive care has extended this appreciation of interprofessional practice to embrace other specialized practitioners from a variety of disciplines in caring for the critically ill. Such disciplines are not limited to medicine and nursing, but include a diverse group of practitioners from areas such as pharmacy, respiratory therapy, nutrition, physical therapy, occupational therapy, social work, palliative care, and pastoral care. Health services researchers have demonstrated improved patient outcomes when this multidisciplinary model is employed.

Collaborative practice in the ICU describes a care model in which the strengths of different practitioners are brought to bear to secure optimal outcomes for patients. In this model, patient care and leadership are shared across disciplines. Care protocols promote advancement toward patient care goals without requiring minute-by-minute physician intervention. Patient care rounds, in which clinical information is shared and decisions made, are usually led by physicians, but nurses, pharmacists, and other members of the ICU team are welcome and are active participants in the formulation of a care plan.

What Are the Benefits of Collaborative Practice in the ICU?

Collaborative practice promotes patient safety and optimal outcomes by encouraging shared responsibility for patient care and harnessing the expertise of each discipline involved. When all members of the ICU team (Table 103.1) take an active role in patient care, care goals are achieved faster and more efficiently and both patient and provider satisfaction are improved. The use of ventilator weaning protocols offers an illustration of the benefits of collaborative practice. In settings where a physician order is required to make any ventilator adjustment, ventilator weaning goals are accomplished more slowly than if respiratory therapists are empowered to make changes according to a protocol.

Secondly, patient safety and coordination of care improve with collaborative practice. Shared care plans and goals of care for patients serve as protection against adverse events such as medication errors, wrong-sided procedures, and resuscitations that patients or families have declined. Many ICUs use checklists to facilitate the formation and communication of care plans. Checklists have been shown to decrease unnecessary variability in care and promote evidence-based practice. An example of a checklist used during interdisciplinary rounds is shown in Figure 103.1.

An additional benefit to collaborative practice is improved team member satisfaction. The ICU is a high-acuity environment in which practitioners are subject to variable degrees of stress and frustration. Collaborative practice and shared ownership of patient care may diffuse some of the anxiety related to caring for the critically ill, contributing to a healthier work environment.