Critical Care Delivery

Abstract

In 2001, the Society of Critical Care Medicine published practice model guidelines that focused on the delivery of critical care and the roles of different ICU team members. An exhaustive review of the additional literature published since the last guideline has demonstrated that both the structure and process of care in the ICU are important for achieving optimal patient outcomes. Since the publication of the original guideline, several authorities have recognized that improvements in the processes of care, ICU structure, and the use of quality improvement science methodologies can beneficially impact patient outcomes and reduce costs. Herein, we summarize findings of the American College of Critical Care Medicine Task Force on Models of Critical Care: 1) An intensivist-led, high-performing, multidisciplinary team dedicated to the ICU is an integral part of effective care delivery; 2) Process improvement is the backbone of achieving high-quality ICU outcomes; 3) Standardized protocols including care bundles and order sets to facilitate measurable processes and outcomes should be used and further developed in the ICU setting; and 4) Institutional support for comprehensive quality improvement programs as well as tele-ICU programs should be provided.

Intensive care unit organisation and nurse outcomes: A cross-sectional study of traditional and “hot-floor” structures

“…[90] Organisational factors also impact the psychological wellbeing of nurses in ICU. [21,91] Burnout resulting from depersonalisation, emotional exhaustion and low personal accomplishment exacerbate this relationship in the work environment and if not proactively managed may result in the ICU hot-floor organisational model, from a nurse workforce perspective, not being sustainable in the long term. [26,30] …”

“…[19] Transition to the hot-floor model requires structural changes to nursing management and education models, supervision and support, staff numbers, resourcing, rostering and staffing. [20][21][22] Key factors to be considered in determining appropriate models and resourcing include the enhanced hotfloor bed flexibility enabling higher patient volumes per bed and high unit occupancy, and the large clinical workforce. Maintaining appropriate staffing and skill-mix on a 24-hour basis, while optimising nurse outcomes, is a major challenge internationally in the ICU.…”

Evaluation of RBC Transfusion Practice in Adult ICUs and the Effect of Restrictive Transfusion Protocols on Routine Care

“…Evidence suggests that organizational interventions such as clinical protocols are important drivers of optimal ICU care[16–19]. Significant opportunities remain to better characterize the adoption of these strategies and describe their effectiveness on improving of ICU care [20, 21].…”

Florence Nightingale and the Conundrum of Counting ICU Beds*

“…Second, the general categories of intensive care unit must be refined and expanded to reflect modern clinical practice. Third, the number of registered nurses, advanced care nurse practitioners, physician assistants, pharmacists, physical therapists, dietitians and social workers should be included in the hospital summaries—such data would be of considerable use in understanding ICU organization (7). Fourth, intensive care bed supply should be stratified into routine and total capacity, with total capacity including beds that could be used if necessary, but that are not staffed for intensive care purposes around the clock (e.g., a post-surgical recovery room bed), providing a more holistic window into each hospitals’ critical care capabilities.…”