Intensive Care Unit Organization, Management, and Value

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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.

4 What can be done to improve the value of intensive care: Checklists, process improvement, and automated decision support?

Nationally, with the average daily costs of an ICU bed now over $3500, critical care costs account for approximately $81.7 billion or 0.66% of the gross domestic product. Not surprisingly, in light of these high costs, hospitals have increased the pressure on administrators and clinician leaders to document the value that ICUs provide to consumers and to the health care system. Value, in this instance, is defined as quality divided by cost, with use of whatever metrics are deemed appropriate by the system. One commonly used metric in the ICU setting is quality-adjusted life years or QALY, which accounts for both the quality and quantity of a patient’s life after the ICU. This metric tries to account for the fact that 1 year of high-quality life after hospitalization is worth more to society than a year of low-quality life. If we then factor in the costs of care, we can begin to make crude estimates of cost-effectiveness by computing the value of interventions as the cost per QALY saved. For instance, these types of analyses have been performed for elderly survivors of critical illness and injury to compare outcome variance dependent on diagnosis and intervention (for example, higher QALY after surgical vs. nonsurgical causes of critical illness).

Because value is defined as quality over cost, value can be improved by either increasing the quality of ICU care (the numerator) and/or decreasing the cost of that care (the denominator). One strategy successful at doing both (increasing quality while decreasing costs) leverages the simple but powerful checklist approach. An effective checklist accomplishes two tasks simultaneously: it ensures that every patient every day receives care that is best practice, and it decreases variance in practice that is deleterious to system efficiency. As one example, checklists as part of a multifaceted approach to system improvement have decreased dramatically the incidence of central line–associated bloodstream infections and their associated costs in the United States over the last decade. This success, coupled with the Institute of Medicine’s report on the impact of preventable hospital errors, has fueled the mushrooming of an industry for quality assurance and performance improvement in medicine. To guide teams in critical care settings, a Society of Critical Care Medicine task force recently reported a how-to guide for quality improvement.

Improving on the pen-and-paper checklist model will require advances in information systems and automated decision analysis. Decision support tools are electronic systems designed to improve clinical decision making by matching individual patients’ characteristics to a computerized knowledge base that generates patient-specific recommendations. When fully implemented, decision support tools can reduce unwanted practice variation and assist with a variety of tasks, including prevention reminders, a list of differential diagnoses, protocolized therapy, and notification of pharmaceutical dosing and drug incompatibilities. Examples in which decision support tools have improved ICU outcomes are antibiotic prescribing in the ICU, compliance with low tidal volume strategies, and glucose control. When selecting electronic decision support tools, it is important to consider a variety of issues, including workflow integration, compatibility with legacy applications, system maturity, and upgrade availability. Effective decision support tools have not supplanted the need for attentive on-site clinicians nor have they proved to undermine clinician education.

5 What is patient- and family-centered care, and how has it changed the approach in the ICU?

The benefits of patient- and family-centered care are widely appreciated. Historically, ICUs have been slow to accommodate the needs of patients’ families, out of either convenience for ICU staff or fear of family-initiated disruptions. Happily, a growing literature strongly supports the patient- and family-centered approach to ICU care, as it improves communication and patient outcomes, including higher patient and family satisfaction. This has motivated a shift in ICU culture. State-of-the-art hospital renovations now include spacious and comfortable waiting areas accompanied by overnight accommodations for immediate family. Family participation on rounds and unrestricted visiting policies improve family satisfaction and may secondarily improve patient outcomes. As part of the quality assurance and process improvement imperative, several validated tools are available to assess family satisfaction: the Critical Care Family Satisfaction Survey (CCFS), Family Satisfaction in the Intensive Care Unit Questionnaire (FS-ICU), and the Critical Care Family Needs Inventory (CCFNI), among others.

6 What is an “ICU without walls,” and how does it affect care before and after ICU admission?

Outcomes are strongly influenced by the care provided before arrival in the ICU, with patients typically being transferred from the emergency department, elsewhere in the hospital (the ward or the operating room), or even another institution. Therefore hospital intensive care operations have been redesigned to provide the “right care, right now,” regardless of where a patient might physically be located. One component of this hospital-wide safety net is the rapid-response team (RRT), which (like the code team) is capable of providing intensive care “outside the walls of the ICU.” RRTs have been widely adopted in the United States and elsewhere to identify patients outside of the ICU at risk for acute organ dysfunction and physiologic deterioration. These activations in turn facilitate escalation of care at the bedside and evaluation for transfer potential to a higher acuity setting, such as an ICU. The U.S. Agency for Healthcare Research and Quality has endorsed the use of rapid-response systems, and the Joint Commission included as a 2008 National Patient Safety Goal the need for systems of care that allow “healthcare staff members to directly request additional assistance from a specially trained individual(s) when the patient’s condition appears to be worsening.” In addition, several studies have addressed the impact of RRTs, yet their benefit in the literature remains controversial. A large, prospective, cluster-randomized trial of RRTs in Australia failed to demonstrate changes in the incidence of cardiac arrest, unplanned ICU admissions, or unexpected deaths. Similarly, a recent meta-analysis examining the effectiveness of rapid-response systems on reducing major adverse events was inconclusive. Nevertheless, ongoing support for rapid-response systems is provided at the national and local levels by the rationale that early intervention is both effective in preventing emergencies and beneficial in limiting adverse consequences. The recent creation of the U.S. Critical Illness and Injury Trials Group provides the framework for testing these and other hypotheses at the national level.

Key Points Intensive Care Unit Organization, Management, and Valueimage

1. Patient outcomes are best in ICUs that are managed by multidisciplinary teams led by an intensivist. For hospitals with multiple ICUs, the Critical Care Center model provides the necessary vision and authority to realize economies of scale, optimized operational efficiencies, and infrastructure to maximize quality care and patient safety.

2. ICU staffing models have a significant impact on both the quality and cost of care. Staffing models shown to improve quality include multidisciplinary teams, intensivist coverage during daytime hours (and perhaps nighttime hours as well), and low patient-to-nurse ratios.

3. Because the demand for critical care clinicians significantly exceeds supply, several approaches are worth exploring to expand the available skill sets, including acute care nurse practitioners, RRTs, telemedicine, and regionalization of intensive care.

4. Health care value is defined as the quality of care divided by its cost. As the cost of ICU care continues to escalate faster than general economic indicators, increased emphasis has been placed on improving value through increased quality and decreased costs. To these ends, systematic approaches to improve performance provide significant benefit.

5. Patient- and family-centered care has been reported to improve outcomes. ICU structure should be evaluated to optimize communication and minimize stress with use of critical care–specific survey tools that measure patient and family satisfaction.

Bibliography

1 Berenholtz S.M., Pronovost P.J., Lipsett P.A., et al. Eliminating catheter-related bloodstream infections in the intensive care unit. Crit Care Med. 2004;32:2014–2020.

2 Cobb J.P. Engineering health in the intensive care unit. Arch Intern Med. 2010;170:319–320.

3 Cobb J.P., Ognibene F.P., Ingbar D.H., et al. Forging a critical alliance: addressing the research needs of the United States critical illness and injury community. Crit Care Med. 2009;37:3158–3160.

4 Curtis J.R., Cook D.J., Wall R.J., et al. Intensive care unit quality improvement: a “how-to” guide for the interdisciplinary team. Crit Care Med. 2006;34:211–218.

5 Dorman T., Paulding R. Is the time right for 24-hr/7-day coverage? Crit Care Med. 2011;39:1544–1545.

6 Garg A.X., Adhikari N.K., McDonald H., et al. Effects of computerized clinical decision support systems on practitioner performance and patient outcomes: a systematic review. JAMA. 2005;293:1223–1238.

7 Halpern N.A., Pastores S.M. Critical care medicine in the United States 2000–2005: an analysis of bed numbers, occupancy rates, payer mix, and costs. Crit Care Med. 2010;38:65–71.

8 Jones D.A., DeVita M.A., Bellomo R. Rapid-response teams. N Engl J Med. 2011;365:139–146.

9 Kaarlola A., Tallgren M., Pettilä V. Long-term survival, quality of life, and quality-adjusted life-years among critically ill elderly patients. Crit Care Med. 2006;34:2120–2126.

10 Kim M.M., Barnato A.E., Angus D.C., et al. The effect of multidisciplinary care teams on intensive care unit mortality. Arch Intern Med. 2010;170:369–376.

11 Lee T.H. Putting the value framework to work. N Engl J Med. 2010;363:2481–2483.

12 Lilly C.M., Cody S., Zhao H., et al. for the University of Massachusetts Memorial Critical Care Operations Group: Hospital mortality, length of stay, and preventable complications among critically ill patients before and after tele-ICU reengineering of critical care processes. JAMA. 2011;305:2175–2183.

13 Nguyen Y.L., Kahn J.M., Angus D.C. Reorganizing adult critical care delivery, the role of regionalization, telemedicine, and community outreach. Crit Care Med. 2010;181:1164–1169.

14 Pronovost P.J., Angus D.C., Dorman T., et al. Physician staffing patterns and clinical outcomes in critically ill patients: a systematic review. JAMA. 2002;288:2151–2162.

15 Tarnow-Mordi W.O., Hau C., Warden A., et al. Hospital mortality in relation to staff workload: a 4-year study in an adult intensive-care unit. Lancet. 2000;356:185–189.

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