Page 41 - ACCCN's Critical Care Nursing

18 S C O P E O F C R I T I C A L C A R E

to provide full, active treatment to all persons. The rule Funding for critical care services has evolved over time
of rescue, or the innate desire to do something – anything to be somewhat separate from mainstream patient
– to help those in dire need, may be a corollary to the funding, owing to the unique requirements of critical
deontological principle. These two concepts, the duty to care units. Critical care is unique because patients are at
act and the rule of rescue, tend to sit well with many the severe end of the disease spectrum. For instance, the
trained and skilled clinicians and the Hippocratic Oath. funding provided for a patient admitted for chronic
In critical care there are some families and some clini- obstructive airway disease in an ICU on a ventilator is
cians who, for personal and/or religious reasons, take a very different from that provided for a patient with the
strong stand and demand treatments and actions based same diagnosis, but treated only in a medical ward. Each
on a deontological view (i.e. the fundamental belief that jurisdictional health department tends to create its own
a certain action is the only one that should be considered unique approach to funding ICU services in its jurisdic-
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in a given situation). tion. For instance, Queensland tends to fund ICU
patients who are specifically identified and defined in
At the other extreme is the utilitarian view, which suggests
an action is right only if it achieves the greatest good for the Clinical Services Capability Framework for Intensive
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the greatest number of people. This concept tends to sit Care with a prescribed price per diem, depending on
well with pragmatic managers and policy makers. An the level of intensive care given to the patient or a price
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example of a utilitarian view might be to ration funding per weighted activity unit, as defined in the business
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allocated to heart transplantation and to utilise any saved rules and updated on an annual basis. In Victoria, the
money for prevention and awareness campaigns. A heart diagnosis-related group (DRG) payment for individual
disease prevention campaign lends a greater benefit to a patient types admitted to the hospital also pays for
greater number in the population than does one trans- ICU episodes, with some co-payment elements added
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plant procedure. for mechanical ventilation. In New South Wales a per
diem rate is established for ICU patients, while high-
The appropriate provision and allocation of critical care dependency patients in ICU are funded through the hos-
services and resources tend to sit somewhere between pital DRG payment; in South Australia a flat per diem
these two extreme positions. This dilemma is true of all rate exists. 9,10 Most other states have a global ICU budget
health services, but critical care, because of its high- payment system based on funded beds or expected occu-
technology, high-cost, low-volume outputs, is under par- pied bed days in the ICU. However, within states and
ticular scrutiny to justify its resource usage within a specific health services and hospitals the actual alloca-
healthcare system. Therefore, not only do critical care tion of funding to the ICU may vary, depending on the
managers need to be prudent, responsible and efficient nature of the specific ICU and demands and priorities
guardians of this precious resource – they need to be seen of the health service. 11
as such if they are to retain the confidence of, and legiti-
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macy with, the broader community values of the day. The RAND study examined funding methods in many
countries and concluded that there was no obvious
example of ‘best practice’ or a dominant approach used
HISTORICAL INFLUENCES by a majority of systems. Each approach had advantages
An often-held view is that managers in government health and disadvantages, particularly in relation to the financial
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services have no incentive to spend or expand services. risk involved in providing intensive care. While the risk
However, the opposite is probably true. Developing larger of underfunding intensive care may be highest in systems
and more sophisticated services such as ICUs can attract that apply DRGs to the entire episode of hospital care,
media and public attention. The 1960s and early 1970s including intensive care, concerns about potential under-
saw the development of the first critical care units in funding were voiced in all systems reviewed. Arrange-
Australia and New Zealand. If a hospital was to be rele- ments for additional funding in the form of co-payments
vant, it had to have one. In fact, what distinguished a or surcharges may reduce the risk of underfunding.
tertiary referral teaching hospital from other hospitals However, these approaches also face the difficulty of
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was, at its fundamental conclusion, the existence of a determining the appropriate level.
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critical care unit. Over time, practical reasons for estab-
lishing critical care units have led to their spread to most At the hospital level, most critical care units have capped
acute hospitals with more than 100 beds. Reasons for the and finite budgets that are linked to ‘open beds’ – that is,
proliferation of critical care services include, but are not beds that are equipped, staffed and ready to be occupied
limited to: by a patient, regardless of whether they are actually occu-
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pied. This is one crude yet common way that hospitals
● economies of scale by cohorting critically ill patients can control costs emanating from the critical care unit.
to one area The other method is to limit the number of trained and
● development of expertise in doctors and nurses who experienced nurses available to the specialty; conse-
specialise in the care and treatment of critically ill quently, a shortage of qualified critical care nurses results
patients in a shortage of critical care beds, resulting in a rationing
● an ever-growing body of research demonstrating that of the service available. The capping of beds and qualified
critically ill patient outcomes are better if patients are critical care nurse positions can be convenient mecha-
cared for in a specifically equipped and staffed critical nisms to limit access and utilisation of this expensive
care unit. 4 service – critical care.