In 1966 Dr B Galbally, a hospital resuscitation officer at St Vincent’s Hospital, Melbourne, published the first article on the planning and organisation of an intensive care unit (ICU) in Australia.¹ He identified that critically ill patients who have a reasonable chance of recovery require life-saving treatments and constant nursing and medical care, but this intensity of service delivery ‘does not necessarily continue until the patient dies, and it should not continue after the patient is considered no longer recoverable’.¹

The need for prudent and rational allocation of limited financial and human resources was as important for Australia’s first ICU (St Vincent’s, Melbourne, 1961) as it is for the 200 or more now scattered across Australia and New Zealand. This chapter explores the influences on the development of critical care and the way this resource is currently viewed and used; describes various organisational, staffing and training arrangements that need to be in place; considers the planning, design and equipment needs of a critical care unit; covers other aspects of resource management including the budget; and finishes with a description of how critical care staff may respond to a pandemic. First, however, important ethical decisions in managing the resources of a critical care unit, which are just as important as the ethical resources that govern the care decisions for an individual patient (see Chapter 6), are discussed below.

Ethical Allocation and Utilisation of Resources

In management, as in clinical practice, careful consideration of the pros and cons of various decisions must be made on a daily basis. The interests of the individual patient, extended family, treating team, bureaucracy and the broader community are rarely congruent, nor are they usually consistent. Decisions surrounding the provision of critical care services are often governed by a compromise between conflicting interests and ethical theories. Two main perspectives on ethical decision making, deontological and utilitarian, are explored briefly.

The deontological principle suggests that a person has a fundamental duty to act in a certain way – for example, to provide full, active treatment to all persons. The rule of rescue, or the innate desire to do something – anything – to help those in dire need, may be a corollary to the deontological principle. These two concepts, the duty to act and the rule of rescue, tend to sit well with many trained and skilled clinicians and the Hippocratic Oath. In critical care there are some families and some clinicians who, for personal and/or religious reasons, take a strong stand and demand treatments and actions based on a deontological view (i.e. the fundamental belief that a certain action is the only one that should be considered in a given situation).

At the other extreme is the utilitarian view, which suggests an action is right only if it achieves the greatest good for the greatest number of people. This concept tends to sit well with pragmatic managers and policy makers.² An example of a utilitarian view might be to ration funding allocated to heart transplantation and to utilise any saved money for prevention and awareness campaigns. A heart disease prevention campaign lends a greater benefit to a greater number in the population than does one transplant procedure.

The appropriate provision and allocation of critical care services and resources tend to sit somewhere between these two extreme positions. This dilemma is true of all health services, but critical care, because of its high-technology, high-cost, low-volume outputs, is under particular scrutiny to justify its resource usage within a healthcare system. Therefore, not only do critical care managers need to be prudent, responsible and efficient guardians of this precious resource – they need to be seen as such if they are to retain the confidence of, and legitimacy with, the broader community values of the day.

Historical Influences

An often-held view is that managers in government health services have no incentive to spend or expand services.³ However, the opposite is probably true. Developing larger and more sophisticated services such as ICUs can attract media and public attention. The 1960s and early 1970s saw the development of the first critical care units in Australia and New Zealand. If a hospital was to be relevant, it had to have one. In fact, what distinguished a tertiary referral teaching hospital from other hospitals was, at its fundamental conclusion, the existence of a critical care unit.⁴ Over time, practical reasons for establishing critical care units have led to their spread to most acute hospitals with more than 100 beds. Reasons for the proliferation of critical care services include, but are not limited to:

• economies of scale by cohorting critically ill patients to one area

• development of expertise in doctors and nurses who specialise in the care and treatment of critically ill patients

• an ever-growing body of research demonstrating that critically ill patient outcomes are better if patients are cared for in a specifically equipped and staffed critical care unit.⁴

Funding for critical care services has evolved over time to be somewhat separate from mainstream patient funding, owing to the unique requirements of critical care units. Critical care is unique because patients are at the severe end of the disease spectrum. For instance, the funding provided for a patient admitted for chronic obstructive airway disease in an ICU on a ventilator is very different from that provided for a patient with the same diagnosis, but treated only in a medical ward. Each jurisdictional health department tends to create its own unique approach to funding ICU services in its jurisdiction.⁵ For instance, Queensland tends to fund ICU patients who are specifically identified and defined in the Clinical Services Capability Framework for Intensive Care⁶ with a prescribed price per diem, depending on the level of intensive care given to the patient or a price per weighted activity unit, as defined in the business rules and updated on an annual basis.⁷ In Victoria, the diagnosis-related group (DRG) payment for individual patient types admitted to the hospital also pays for ICU episodes, with some co-payment elements added for mechanical ventilation.⁸ In New South Wales a per diem rate is established for ICU patients, while high-dependency patients in ICU are funded through the hospital DRG payment; in South Australia a flat per diem rate exists.^9,¹⁰ Most other states have a global ICU budget payment system based on funded beds or expected occupied bed days in the ICU. However, within states and specific health services and hospitals the actual allocation of funding to the ICU may vary, depending on the nature of the specific ICU and demands and priorities of the health service.¹¹

The RAND study¹² examined funding methods in many countries and concluded that there was no obvious example of ‘best practice’ or a dominant approach used by a majority of systems. Each approach had advantages and disadvantages, particularly in relation to the financial risk involved in providing intensive care. While the risk of underfunding intensive care may be highest in systems that apply DRGs to the entire episode of hospital care, including intensive care, concerns about potential underfunding were voiced in all systems reviewed. Arrangements for additional funding in the form of co-payments or surcharges may reduce the risk of underfunding. However, these approaches also face the difficulty of determining the appropriate level.¹²

At the hospital level, most critical care units have capped and finite budgets that are linked to ‘open beds’ – that is, beds that are equipped, staffed and ready to be occupied by a patient, regardless of whether they are actually occupied.¹³ This is one crude yet common way that hospitals can control costs emanating from the critical care unit. The other method is to limit the number of trained and experienced nurses available to the specialty; consequently, a shortage of qualified critical care nurses results in a shortage of critical care beds, resulting in a rationing of the service available. The capping of beds and qualified critical care nurse positions can be convenient mechanisms to limit access and utilisation of this expensive service – critical care.

Funding based on achieving positive patient outcomes would be ideal, as it would ensure that critical care units were using their resources only for those patients who were most likely to achieve positive outcomes in terms of morbidity and mortality, but such an ideal has not developed sufficiently to date. Funding based on health outcomes only does, however, raise the risk of encouraging clinicians to ‘cherry-pick’ only the most ‘profitable’ or ‘successful’ patient groups at the expense of others. In private (for-profit) hospitals or countries with very poor health systems, ‘cherry-picking’ only those patients for whom a successful outcome is guaranteed is likely to be more common, whereas in the public hospitals of most Western countries an educated guess/risk is often applied to the decision as to whether a patient should enter the critical care unit or not.

It is vital to note the very important role played by rural and isolated health services and, in particular, critical care units and outreach services in these regions. Many of the contemporary activity-based funding formulas are difficult to apply to these settings. There are diseconomies of scale in such settings as a result of small bed numbers, limited but highly skilled nurses and doctors, and unpredictable peaks and troughs in demand, which make workforce planning and the management of call-in/overtime and fatigue problems difficult for small teams to manage. The professional isolation and limited access to education, training and peer support can also create morale problems for some members of the team. Furthermore, the diseconomies and isolation require empathetic funding processes to recognise the difficulties unique to regional and isolated critical care services. If such units are to remain viable and capable of delivering levels of safe and effective care equivalent to those expected in larger metropolitan hospitals, then additional funding and support is required to compensate for the cost and tyranny of distance.

Economic Considerations and Principles

One early comprehensive study of costs found that 8% of patients admitted to the ICU consumed 50% of resources but had a mortality rate of 70%, while 41% of patients received no acute interventions and consumed only 10% of resources.¹⁴ More recent Australian studies show that, although critical care service is increasingly being provided to patients with a higher severity of acute and chronic illnesses, long-term survival outcome has improved with time, suggesting that critical care service may still be cost-effective despite the changes in case-mix.^15,¹⁶

An Australian study showed that in 2002, ICU patients cost around $2670 per day or $9852 per ICU admission, with more than two-thirds going to staff costs, one-fifth to clinical consumables and the rest to clinical support and capital expenditure.¹⁷ Nevertheless, some authors provide scenarios as examples of poor economic decision making in critical care and argue for less extreme variances in the types of patient ICUs choose to treat in order to reduce the burden of the health dollar.^18,¹⁹ Others have suggested that if all healthcare provided were appropriate, rationing would not be required.³ Defining what is ‘appropriate’ can be subjective, although not always. The RAND^12,²⁰ group suggests that there are at least three approaches that can be used to assess appropriateness of care (Table 2.1). These include the benefit–risk, benefit–cost and implicit approaches.

TABLE 2.1 Approaches to assessing treatment options¹²

Approach	Description
Benefit–risk approach	The benefit of treatment and the inherent risks to the patient are assessed to inform a decision; this approach excludes monetary costs.
Benefit–cost approach	Evaluate the benefit and cost of the decision to proceed; this approach incorporates cost to patient and society.
Implicit approach	The medical practitioner provides the service and judges its appropriateness.

The first two approaches are considered to be explicit approaches, while the third tends to be subjective. However, all approaches have a subjective element. While the implicit approach is considered to be subjective in nature, the medical practitioner must contemplate ‘benefit–risk’ and ‘benefit–cost’ considerations but should also involve the patient/family in the contemplation and ultimate decision. What is best for the patient is not just the opinion of the treating doctor and needs to be considered in much broader terms, such as the patient’s previous expressed wishes and the family’s opinion as de-facto patient representatives. The quality of the decision and the quality of the expected outcome require many competing considerations.

The ‘quality’ agenda in healthcare has argued for ‘best practice’ and ‘best outcomes’ in the provision of health services, although it may be more pragmatic to consider ‘value’ when discussing what is and what is not an appropriate decision in critical care. The following equation expresses the concept ‘value’ simply:

The quality of the outcome is a function of the benefit to be achieved and the sustainability of the benefit. The benefit of critical care is associated with such factors as survival, longevity and improved quality of life (e.g. greater functioning capacity and less pain and anxiety). The benefit is enhanced by sustainability: the longer the benefit is maintained, the better it is.²¹

Cost is separated into two components, monetary (price) and non-monetary (suffering). Non-monetary costs include such considerations as morbidity, mortality, pain and anxiety in the individual, or broader societal costs and suffering (e.g. opportunity costs to others who might have used the resources but for the current occupants, and what other health services might have been provided but for the cost of this service).²¹

Ethico-economic analyses of services like critical care and expensive treatments like organ transplantation are the new consideration of this century and are as important to good governance as are discussions of medico-legal considerations. Sound ethical principles to inform and guide human and material resource management and budgets ought to prevail in the management of critical care resources.²

Budget

This section provides information on types of budget, the budgeting process, and how to analyse costs and expenditure to ensure that resources are utilised appropriately. As noted by one author, ‘Nothing is so terrifying for clinicians accustomed to daily issues of life and death as to be given responsibility for the financial affairs of their hospital division!’.³ Yet, in essence, developing and managing a budget for a critical care unit follows many of the same principles as managing a family budget. Consideration of value for money, prioritising needs and wants, and living within a relatively fixed income is common to all. This section in no way undermines the skill and precision provided by the accounting profession, nor will it enable clinicians to usurp the role of hospital business managers. Rather, the aim is to provide the requisite knowledge to empower clinicians to manage the key components of budget development and budget setting, and to know what questions to ask when confronted by this most daunting responsibility of managing a unit’s or service’s budget.

Types of Budget

There are essentially three types of budget that a manager must consider: personnel, operational and capital. Within these budget types, there are two basic cost types: fixed and variable. Fixed costs are those essential to the service and are relatively constant, regardless of the fluctuations in workload or throughput (e.g. nurse unit manager salary, security, ventilators). Variable costs change with changing throughput (e.g. nurse agency usage or staff overtime), especially if used in response to influx of demand and resulting consumables such as linen, dressings and drugs.

Budget Process

The budget includes three fundamental steps: budget preparation and approval, budget analysis and reporting, and budget control or action.

Budget Preparation and Approval

A budget plan essentially runs in parallel with a unit or service management plan, forecasting likely activity and resulting financial costs. In most circumstances the preceding year’s activity and costs are a good benchmark on which to base the next year’s budget. However, hospital expectations in terms of new services, greater patient throughput or changes to staff entitlements will need to be factored into the new budget.

The budget period is generally a financial year, but developing monthly budgets (cash flowing) to coincide with predictable variations allows for a more realistic representation of how costs are incurred and paid throughout the financial year period. If the budget plan is well constructed, one always hopes and expects the final budget allocation (i.e. the approved budget) to be close to achievable.

Budget Analysis and Reporting

Most critical care managers analyse their expenditure against budget projections on a monthly basis, to identify variances from planned expenditure. Information should not merely be financial: a breakdown of the monthly and year-to-date expenditures for personnel (productive and non-productive), and operational (fixed and variable) costs, should be matched against other known measurable indicators of activity or productivity (e.g. patient bed-days, patient types/DRGs and staffing hours, including overtime and other special payments).³

One common management maxim is: if it cannot be measured, then it cannot be controlled. Clinical managers therefore need to work closely with finance managers to develop consistent data measurements and reports to inform themselves and staff about where they should focus their efforts to achieve the approved budget target.

Budget Control and Action

When signs of poor performance or financial overrun are evident, managers cannot merely analyse the financial reports, hoping that things will sort themselves out. Every variance of a sizeable amount requires an explanation. Some will be obvious: an outbreak of community influenza among staff will increase sick leave and casual staff costs for a period of time. Other overruns can be insidious but no less important: overtime payments, although sometimes unavoidable, can also reflect poor time management or a culture of some staff wanting to boost their income surreptitiously.²²

An effective method of controlling the budget is actively to engage staff in the process of managing costs. Managers can explain to staff how the budget has been developed and how their performance against budget is progressing, and identify areas for potential improvement. Seeking ideas from staff on how to improve efficiency and productivity and giving them some responsibility for the budget performance can encourage an esprit de corps and improvements from the whole team that a single manager cannot achieve alone.

Developing A Business Case

The most common reason for writing a business case is to justify the resources and capital expenditure to gain the support and/or approval for a change in service provision and/or purchase of a significant new piece of equipment/technology. This section provides an overview of a business case and a format for its presentation. The business case can be an invaluable tool in the strategic decision-making process, particularly in an environment of constrained resources.²³

A business case is a management tool that is used in the process of meeting the overall strategic plan of an organisation. Within a setting such as healthcare, the business case is required to outline clearly the clinical need and implications to be understood by leaders. Financial imperatives, such as return on investment, must also be defined and identified.²³^–²⁵ A business case is a document in which all the facts relevant to the case are documented and linked cohesively. Various templates are available (see Online Resources) to assist with the layout. key questions are generally the starting point for the response to a business case: why, what, when, where and how, with each question’s response adding additional information to the process (Table 2.2). Business cases can vary in length from many pages to just a couple. Most organisations will have standardised headings and formats for the presentation of these documents. If the document is lengthy, the inclusion of an executive summary is recommended, to summarise the salient points of the business case (Box 2.1).

TABLE 2.2 key questions in writing a business case

Question	Example
Why?	What is the background to the project, and why is it needed: PEST (political, economic, sociological, technological) and SWOT (strengths, weaknesses, opportunities and threats) analysis?
What?	Clearly identify and define the project and the purpose of the business case and outline the solution. Clearly defined, measurable benefits should be documented; goals and outcomes.
What if?	A risk assessment of the current situation, including any controls currently in place to address/mitigate the issue, and a risk assessment following the implementation of the proposed solution.
When?	What are the timelines for the implementation and achievement of the project/solution?
Where?	What is the context within which the project will be undertaken, if not already included in the background material?
How?	How much money, people and equipment, for example, will be required to achieve the benefits? A clear cost–benefit analysis should be included in response to this question.

Box 2.1 Business case

Sample headings

Cost–benefit analysis

Recommendations

Risk assessment

In summary, the business case is an important tool that is increasingly required at all levels of an organisation to clearly define a proposed change or purchase. This document should include clear goals and outcomes, a cost-benefit analysis and timelines for achievement of the solution.

Critical Care Environment

A critical care unit is a distinct unit within a hospital that has easy access to the emergency department, operating theatre and medical imaging. It provides care to patients with a life-threatening illness or injury and concentrates the clinical expertise and technological and therapeutic resources required.²⁶ The College of Intensive Care Medicine (CICM) defines three levels of intensive care to support the role delineation of a particular hospital, dependent upon staffing expertise, facilities and support services.²⁷ Critical care facilities vary in nature and extent between hospitals and are dependent on the operational policies of each individual facility. In smaller facilities, the broad spectrum of critical care may be provided in combined units (intensive care, high-dependency, coronary care) to improve flexibility and aid the efficient use of available resources.²⁶

Organisational Design

The functional organisational and unit designs are governed by available finances, an operational brief and the building and design standards of the state or country in which the hospital is located. A critical care unit should have access to minimum support facilities, which include staff station, clean utility, dirty utility, store room(s), education and teaching space, staff amenities, patients’ ensuites, patients’ bathroom, linen storage, disposal room, sub-pathology area and offices. Most notably, the actual bed space/care area for patients needs to be well designed.²⁶

The design of the patient’s bed-space has received considerable attention in the past few years. In Australia, most state governments have developed minimum guidelines to assist in the design process. Each bed space should be a minimum of 20 square metres and provide for visual privacy from casual observation. At least one handbasin per single room or per two beds should be provided to meet minimum infection control guidelines.²⁶ Each bed space should have piped medical gases (oxygen and air), suction, adequate electrical outlets (essential and non-essential), data points and task lighting sufficient for use during the performance of bedside procedures. Further detailed descriptions are available in various health department documents.²⁶

Equipment

Since the advent of critical care units, healthcare delivery has become increasingly dependent on medical technology to deliver that care. Equipment can be categorised into several funding groups: capital expenditure (generally in excess of $10,000), equipment expenditure (all equipment less than $10,000), and the disposable products and devices required to support the use of equipment. This section examines how to evaluate, procure and maintain that equipment.

Initial Set-Up Requirements

Critical care units require baseline equipment that allows the unit to deliver safe and effective patient care. The list of specific equipment required by each individual unit will be governed by the scope of that unit’s function. For example, a unit that provides care to patients after neurosurgery will require the ability to monitor intracranial pressure. Table 2.3 lists the basic equipment requirements for a critical care unit.

TABLE 2.3 Basic equipment requirements

Monitoring	Therapeutic
Monitors (including central station) End-tidal CO2 monitoring Arterial blood gas analyser (±electrolytes) Invasive monitoring • arterial • central venous pressure • intracranial pressure • PiCCO • pulmonary artery Access to image intensifier Ultrasound Access to CT/MRI

Ventilators (invasive and non-invasive)

CT = computerised tomography; CVVHDF = continuous veno-venous haemodiafiltration; EDD-f = extended daily dialysis filtration; MRI = magnetic resonance imaging; PiCCO = pulse-induced contour cardiac output.

Purchasing

The procurement of any equipment or medical device requires a rigorous process of selection and evaluation. This process should be designed to select functional, reliable products that are safe, cost-effective and environmentally conscious and that promote quality of care while avoiding duplication or rapid obsolescence.²⁸ In most healthcare facilities, a product evaluation committee exists to support this process, but if this is not the case it is strongly recommended that a multidisciplinary committee be set up, particularly when considering the purchase of equipment requiring capital expenditure.²⁹

The product evaluation committee should include members who have an interest in the equipment being considered and should comprise, for example, biomedical engineers and representatives from the central sterile supply unit (CSSU), administration, infection control, end users and other departments that may have similar needs. Once a product evaluation committee has been established, clear, objective criteria for the evaluation of the product should be determined (Box 2.2). Ideally, the committee will screen products and medical devices before a clinical evaluation is conducted to establish its viability, thus avoiding any unnecessary expenditure in time and money.²⁸

The decision to purchase or lease equipment will, to some extent, be governed by the purchasing strategy approved by the hospital or state government. The advantages of leasing equipment include the capital expenditure being defrayed over the life of the lease (usually 36 months), with ongoing servicing and product upgrades built into the lease agreement and price structure. Any final presentation from the product evaluation committee should therefore include a recommendation to purchase or lease, based on a cost–benefit analysis of the ongoing expenditure required to maintain the equipment.

Replacement and Maintenance

The process for replacement of equipment is closely aligned with the process for the purchase of new equipment. The stimulus for the process to begin, however, can be either the condemning of equipment by biomedical engineers or the planned replacement of equipment nearing the end of its life cycle. In general, capital equipment is deemed to have a life cycle of five years. This time frame takes into account both the longevity of the physical equipment and its technology.

Ongoing maintenance of equipment is an important part of facilitating safety within the unit. Maintenance may be provided in-house by individual facility biomedical departments or as part of a service contract arrangement with the vendor company. The provision of a maintenance/service plan should be clearly identified during the procurement phase of the equipment’s purchase process. While equipment maintenance is not the direct responsibility of the nurses in charge of the unit, they should be aware of the maintenance plan for all equipment and ensure that timely maintenance is undertaken.

Routine ongoing care of equipment is outlined in the product information and user manuals that accompany devices. This documentation clearly outlines routine care required for cleaning, storage and maintenance. All staff involved in the maintenance of clinical equipment should be trained and competent to carry it out. As specialist equipment is a fundamental element of critical care, effective resourcing includes consideration of the purchase, set-up, maintenance and replacement of equipment. Equipment is therefore an important aspect of the budget process.

Staff

Staffing critical care units is an important human resource consideration. The focus of this section is on nursing staff, although the important role that medical staff and other ancillary health personnel provide is acknowledged. Nurses’ salaries consume a considerable portion of any unit budget and, owing to the constant presence of nurses at the bedside, appropriate staffing plays a significant role in the quality of care delivered. Nurse staffing levels influence patient outcomes both directly, through the initiation of appropriate nursing care strategies, and indirectly, by mediating and implementing the care strategies of other members of the multidisciplinary healthcare team. Therefore, ensuring an appropriate skill mix is an important aspect of unit management. This section considers how appropriate staffing levels are determined and the factors, such as nurse–patient ratios and skill mix, that influence them.

Staffing Roles

There are a number of different nursing roles in the ICU nursing team, and various guidelines determine the requirements of these roles. Both the Australian College of Critical Care Nurses (ACCCN) (see Appendix B2) and the World Federation of Critical Care Nurses (WFCCN) (see Appendix A2) have position statements surrounding the critical care workforce and staffing. A designated nursing manager (nursing unit manager/clinical nurse consultant/nurse practice coordinator/clinical nurse manager, or equivalent title) is required for each unit to direct and guide clinical practice. The nurse manager must possess a post-registration qualification in critical care or in the clinical specialty of the unit.^27,³⁰ A clinical nurse educator (CNE) should be available in each unit. The ACCCN recommends a minimum ratio of one full-time equivalent (FTE) CNE for every 50 nurses on the roster, to provide unit-based education and staff development.^27,³⁰ The clinical nurse consultant (CNC) role is utilised at the unit, hospital and area health service level to provide resources, education and leadership.³⁰ Registered nurses within the unit are generally nurses with formal critical care postgraduate qualifications and varying levels of critical care experience.

Prior to the mid-1990s, when specialist critical care nurse education moved into the tertiary education sector, critical care education took the form of hospital-based certificates.³¹ Since this move, postgraduate, university-based programs at the graduate certificate or postgraduate diploma level are now available, although some hospital-based courses that articulate to formal university programs continue to be accessible. The ACCCN (see Appendix B1) and the WFCCN (see Appendix A1) have developed position statements on the provision of critical care nursing education. Various support staff are also required to ensure the efficient functioning of the department, including, but not limited to, administrative/clerical staff, domestic/ward assistant staff and biomedical engineering staff.