Page 46 - Hall et al (2015) Principles of Critical Care-McGraw-Hill

CHAPTER 3: Intensive Care Unit Staffing 15

and teamwork have also been proposed as markers of quality and may CHAPTER Intensive Care Unit Staffing
provide a different perspective.
3 Allan Garland
CONCLUSIONS Hayley Beth Gershengorn

Quality metrics are required to drive quality improvement initiatives in Constantine A. Manthous
ICUs. The science of quality improvement is still young in health care
and many efforts, including public reporting and benchmarking, have
not shown benefit for the health care system. Quality of health care, KEY POINTS
like many social science constructs, has many different domains, which • Most studies addressing staffing of ICUs have had significant limi-
may not necessarily converge as a single number. This is frustrating for tations, and this literature does not yet provide a consistent view of
consumers and payers who would prefer to have a rating system for the best model to use. This subject is complicated by the fact that
health care as they have for televisions, automobiles, and restaurants. optimal ICU staffing may depend on ICU characteristics.
Unfortunately, no single measure meets all of the criteria for specificity,
measurability, actionability, relevance, and timeliness achievable in the • Despite calls for all ICUs to function as closed-model units with
intensivists as the primary physician of record, evidence support-
business world. This is partially tied to the inadequacy of core outcome
measurements such as mortality and the possibility of bias in collect- ing this view is contradictory. Likewise, studies of around-the-
clock intensivist presence have not consistently shown that it is
ing other measures. The future of quality improvement will need to
balance an increasingly demanding consumer and payer group, which associated with superior outcomes.
seeks publically reported data with the potential unintended negative • The data do not supply a consistent answer to the question of
consequences of those activities. Ideally, payers will identify incentives whether ICUs would obtain better outcomes if they added nurses
to get hospitals to engage in local quality improvement activities that to reduce their patient:nurse ratios.
rely on internally selected evidence-based process measures rather than • Increasingly, nonphysician providers are playing innovative roles
externally mandated benchmarking or a reasonable balance of these in the ICU, and care provided by teams including nurse practitio-
activities. ners or physician assistants appears to be safe and comparable to
that provided by other staffing models.
KEY REFERENCES • The conditions of ICU staffing will continue to change under the
stresses of shortages of a variety of health care workers relevant to
• Benneyan JC. Statistical quality control methods in infection ICU care, and increasing duty hour limitations for physician train-
control and hospital epidemiology, part I: Introduction and basic ees. Nonphysician providers, innovative staffing models, telemedi-
theory. Infect Control Hosp Epidemiol. 1998;19:194-214. cine, and other technologies will be increasingly used to cope with
• Cable G. Enhancing causal interpretations of quality improvement these realities.
interventions. Qual Health Care. 2001;10:179-186. • Since only quantitative evaluation can tell us whether one staffing
• Caplan RA, Posner KL, Cheney FW. Effect of outcome on phy- model is better than another, we need more research from multiple
sician judgments of appropriateness of care. JAMA. 1991;265: sites to develop a consistent and integrated understanding of this
1957-1960. complex topic.
• Fung CH, Lim YW, Mattke S, Damberg C, Shekelle PG. Systematic
review: the evidence that publishing patient care performance data
improves quality of care. Ann Intern Med. 2008;148:111-123. INTRODUCTION
• Hofer TP, Hayward RA. Identifying poor-quality hospitals. Can Like all complex organizations, intensive care units (ICUs) have numer-
hospital mortality rates detect quality problems for medical diag- ous variable elements of organization and structure, including how they
noses? Med Care. 1996;34:737-753. are staffed. Outside of medicine, it is widely accepted that most of the
• Kahn JM, Goss CH, Heagerty PJ, Kramer AA, O’Brien CR, opportunities to improve the performance of complex organizations
Rubenfeld GD. Hospital volume and the outcomes of mechanical derive from improving the structures and processes of which they con-
ventilation. N Engl J Med. 2006;355:41-50. sist. Within this systems-based concept, every aspect of what we do and
• Kim MM, Barnato AE, Angus DC, Fleisher LF, Kahn JM. The how we do it is a candidate for study and change, including all aspects of
1
effect of multidisciplinary care teams on intensive care unit mor- ICU staffing. Though a variety of types of health care workers (HCWs)
2
tality. Arch Intern Med. 2010;170:369-376. collaborate in caring for ICU patients, relatively little is known about
• Levy MM, Rapoport J, Lemeshow S, Chalfin DB, Phillips G, the relationships between ICU staffing and outcomes. It is rare for staff-
ing patterns to be the result of an evidence-based assessment of what
Danis M. Association between critical care physician management works best; they usually reflect historical precedents, combined with
and patient mortality in the intensive care unit. Ann Intern Med. practical necessities and growth by accretion.
2008;148:801-809. Staffing options can be framed as a number of questions, such as:
• Needleman J, Buerhaus P, Mattke S, Stewart M, Zelevinsky K. Who does it?, How many of them are there to do it?, What do they do?,
Nurse-staffing levels and the quality of care in hospitals. N Engl J and How do they do it? These address the type, training, experience, and
Med. 2002;346:1715-1722. other characteristics of the HCWs; details of work schedules, including
• Wallace DJ, Angus DC, Barnato AE, Kramer AA, Kahn JM. workload, duty hours, shiftwork, and coverage for nights and weekends;
Nighttime intensivist staffing and mortality among critically ill details of assigned tasks; and interfaces between different types of HCW.
patients. N Engl J Med. 2012;366:2093-2101. Not only is all of this highly complex and interacting, but the optimal
staffing structure for a given ICU may well differ based on ICU type,
size, case mix, and other differences of baseline structure.
In this chapter, we review existing evidence addressing relationships
REFERENCES between ICU staffing and outcomes. We will discuss intensivists, hospi-
talists, house officers, physician extenders, nurses, respiratory therapists,
Complete references available online at www.mhprofessional.com/hall pharmacists, and telemedicine. As it cannot be assumed that what works

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