31. ICU Administration

Care should be provided by a multidisciplinary team that consists of intensivists (physician ICU experts), nurses, respiratory and physical therapists, clinical pharmacists and nutritionists.

The multidisciplinary team approach has not only been shown to improve patient outcomes, but also the efficiency and cost effectiveness for patients in the ICU.

Optimal performance is critically dependent upon open communication across disciplines, which demonstrates respect and a willingness to listen to all.

Administrative Models

Open unit

Patients may be admitted and cared for by all qualified physicians as defined by the hospital’s credentialing policies.

Patients usually remain on the attending’s service with intensivist involvement only after a formal consult for care.

Semi-closed unit

In a semi-closed unit, the intensivist has the authority to reject requests for admission and typically sees all patients admitted to the ICU.

Closed unit

The intensivist in a closed unit assumes direct responsibility as the attending physician.

The patient is transferred to the intensivist’s service upon ICU admission and transferred back to the original attending upon ICU discharge.

Patient care is generally managed by the multidisciplinary critical care team in collaboration with the admitting attending.

In some units the ICU team may be the only medical team caring for the patient.

Value of Critical Care

Nationally, with the average daily costs of an ICU bed now over $3,500, critical care costs account for approximately $81.7B or 0.66% of the gross domestic product (GDP).

In an ICU setting, value is defined as quality divided by cost, using 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.

When cost of care is factored in, crude estimates can be made of cost effectiveness by computing the value of interventions as the cost per QALY saved.

For example, such analyses could be performed for elderly survivors of critical illness and injury.

The QALY for surgical versus nonsurgical interventions could help guide therapy.

Improve value

Value can be improved by either increasing the quality of ICU care (the numerator) and/or decreasing the cost of that care (the denominator).

Checklists

The checklist approach is simple and insures that every day, every patient receives care that is best practice and decreases any variance in practice that is deleterious to system efficiency.

Process improvement

Process improvements can only be successful when there is continuous evaluation to sustain effective program requirements, ongoing observation, periodic data collection and interpretation, behavior change as needed, and infrastructure support.

Decision support tools

Decision support tools are electronic systems designed to improve clinical decision making by matching individual patient characteristics to a computerized knowledge base that generates patient-specific recommendations.

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, notification of pharmaceutical dosing, and drug incompatibilities.

Quality Assurance/Quality Improvement

Quality of health care has been defined by the Institute of Medicine as care that is safe, timely, effective, efficient, equitable, and patient centered.

Donabedian’s structure, process, and outcome model provides a useful framework for understanding and improving the quality of health care. A comprehensive ICU quality improvement program will usually address measures in each of these three categories and may also consider the structures, processes, and outcomes outside the ICU that affect the quality of care.

Structure is defined as the way we organize care.

Sources of structural variation include how the ICU is integrated into the hospital or health care system, the size of the ICU, whether the unit is open or closed, the type and amount of technology available, and the number, roles, and responsibilities of ICU staff.

Variation in these structural features can affect the quality of care and therefore the potential for recovery from critical illness.

Process refers to what we do, or fail to do, for patients and their families.

Delivering high-quality care in the ICU requires the synchronous efforts of large numbers of clinical and nonclinical processes.

Examples of process measures in the ICU include rate of deep vein thrombosis (DVT) prophylaxis, rate of stress ulcer prophylaxis, appropriate transfusion threshold, blood glucose control, hand washing, low tidal volume, and ventilation in acute lung injury (ALI)/acute respiratory distress syndrome (ARDS)

Nonclinical processes of the ICU, such as the process of organizational management, can also have an important effect on quality.

Outcomes represent the third component of the quality-of-care model and refer to the results we achieve.

Examples of outcome measures in the ICU include severity-adjusted mortality rate, health-related quality of life, unplanned readmissions to ICU, CVC bloodstream infection rate, and family satisfaction.