The Performance of Intensive Care Units: Does Good Management Make a Difference?

Center for Health Services and Policy Research, Northwestern University, Evanston, IL 60208-2007.
Medical Care (Impact Factor: 3.23). 06/1994; 32(5):508-25. DOI: 10.1097/00005650-199405000-00009
Source: PubMed


A significant portion of health care resources are spent in intensive care units with, historically, up to two-fold variation in risk-adjusted mortality. Technological, demographic, and social forces are likely to lead to an increased volume of intensive care in the future. Thus, it is important to identify ways of more efficiently managing intensive care units and reducing the variation in patient outcomes. Based on data collected from 17,440 patients across 42 ICUs, the present study examines the factors associated with risk-adjusted mortality, risk-adjusted average length of stay, nurse turnover, evaluated technical quality of care, and evaluated ability to meet family member needs. Using the Apache III methodology for risk-adjustment, findings reveal that: 1) technological availability is significantly associated with lower risk-adjusted mortality (beta = -.42); 2) diagnostic diversity is significantly associated with greater risk-adjusted mortality (beta = .46); and 3) caregiver interaction comprising the culture, leadership, coordination, communication, and conflict management abilities of the unit is significantly associated with lower risk-adjusted length of stay (beta = .34), lower nurse turnover (beta = -.36), higher evaluated technical quality of care (beta = .81), and greater evaluated ability to meet family member needs (beta = .74). Furthermore, units with greater technological availability are significantly more likely to be associated with hospitals that are more profitable, involved in teaching activities, and have unit leaders actively participating in hospital-wide quality improvement activities. The findings hold a number of important managerial and policy implications regarding technological adoption, specialization, and the quality of interaction among ICU team members. They suggest intervention "leverage points" for care givers, managers, and external policy makers in efforts to continuously improve the outcomes of intensive care.

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    • "Several other studies have demonstrated significant associations between the level of teamwork and ICU outcomes. For example, positive caregiver interaction among ICU clinicians was associated with shortened length of stay [16]. Better leadership, conflict resolution, and coordination were associated with lower incidents of periventricular/intraventricular hemorrhage or periventricular leukomalacia [17]. "
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    ABSTRACT: Purpose Teamwork is essential for ensuring the quality and safety of healthcare delivery in the intensive care unit (ICU). This article addresses what we know about teamwork, team tasks, and team improvement strategies in the ICU to identify the strengths and limitations of the existing knowledge base to guide future research. Methods A key word search of the PubMed database was conducted in February 2013. Key word combinations focused on three areas: (1) teamwork, (2) the ICU, and (3), training/quality improvement interventions. All studies that investigated teamwork, team tasks, or team interventions within the ICU (i.e., intradepartment) were selected for inclusion. Results Teamwork has been investigated across an array of research contexts and task types. The terminology used to describe team factors varied considerably across studies. The most common team tasks involved strategy and goal formulation. Team training and structured protocols were the most widely implemented quality improvement strategies. Conclusions Team research is burgeoning in the ICU, yet low hanging fruit remains that can further advance the science of teams in the ICU if addressed. Constructs must be defined and theoretical frameworks should be referenced. The functional characteristics of tasks should also be reported to help determine the extent to which study results might generalize to other contexts of work.
    Journal of Critical Care 12/2014; 29(6). DOI:10.1016/j.jcrc.2014.05.025 · 2.00 Impact Factor
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    • "Each of these studies was conducted in a single unit. However, in seven studies there was insufficient evidence to reject the null hypothesis of no relationship between staffing levels and mortality (Audit Commission, 1999; Bastos et al., 1996; Dimick et al., 2001; Pronovost et al., 1999, 2001; Reis-Miranda et al., 1998; Shortell et al., 1994). Interestingly, these were all multiunit studies. "
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    ABSTRACT: Objectives To investigate whether the size of the workforce (nurses, doctors and support staff) has an impact of the survival chances of critically ill patients both in the intensive care unit (ICU) and in the hospital. Background Investigations of intensive care outcomes suggest that some of the variation in patient survival rates might be related to staffing levels and workload, but the evidence is still equivocal. Data: Information about patients, including the outcome of care (whether the patient lived or died) came from the Intensive Care National Audit & Research Centre (ICNARC) Case Mix Programme. An Audit Commission survey of ICUs conducted in 1998 gave information about staffing levels. The merged dataset had information on 65 ICUs and 38,168 patients. This is currently the best available dataset for testing the relationship between staffing and outcomes in UK ICUs Design A cross-sectional, retrospective, risk adjusted observational study. Methods Multivariable, multilevel logistic regression. Outcome Measures: ICU and in-hospital mortality. Results After controlling for patient characteristics and workload we found that higher numbers of nurses per bed (odds ratio: 0.90, 95% confidence interval: [0.83, 0.97]) and higher numbers of consultants (0.85, [0.76, 0.95]) were associated with higher survival rates. Further exploration revealed that the number of nurses had the greatest impact on patients at high risk of death (0.98, [0.96, 0.99]) whereas the effect of medical staffing was unchanged across the range of patient acuity (1.00, [0.97, 1.03]). No relationship between patient outcomes and the number of support staff (administrative, clerical, technical and scientific staff) was found. Distinguishing between direct care and supernumerary nurses and restricting the analysis to patients who had been in the unit for more than 8 hours made little difference to the results. Separate analysis of in-unit and in-hospital survival showed that the clinical workforce in intensive care had a greater impact on ICU mortality than on hospital mortality which gives the study additional credibility. Conclusion This study supports claims that the availability of medical and nursing staff is associated with the survival of critically ill patients and suggests that future studies should focus on the resources of the health care team. The results emphasise the urgent need for a prospective study of staffing levels and the organisation of care in ICUs.
    International journal of nursing studies 05/2014; 51(5). DOI:10.1016/j.ijnurstu.2014.02.007 · 2.90 Impact Factor
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    • "Whilst research on neglect has not focussed on leadership, research has demonstrated the importance of effective medical, nursing and managerial leadership (e.g. providing clarity on goals, encouraging open communication, creating opportunities for improving care) for ensuring quality of care and patient satisfaction [79-81]. Thus it is of considerable importance for understanding the occurrence of patient neglect. "
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    ABSTRACT: Background Patient neglect is an issue of increasing public concern in Europe and North America, yet remains poorly understood. This is the first systematic review on the nature, frequency and causes of patient neglect as distinct from patient safety topics such as medical error. Method The Pubmed, Science Direct, and Medline databases were searched in order to identify research studies investigating patient neglect. Ten articles and four government reports met the inclusion criteria of reporting primary data on the occurrence or causes of patient neglect. Qualitative and quantitative data extraction investigated (1) the definition of patient neglect, (2) the forms of behaviour associated with neglect, (3) the reported frequency of neglect, and (4) the causes of neglect. Results Patient neglect is found to have two aspects. First, procedure neglect, which refers to failures of healthcare staff to achieve objective standards of care. Second, caring neglect, which refers to behaviours that lead patients and observers to believe that staff have uncaring attitudes. The perceived frequency of neglectful behaviour varies by observer. Patients and their family members are more likely to report neglect than healthcare staff, and nurses are more likely to report on the neglectful behaviours of other nurses than on their own behaviour. The causes of patient neglect frequently relate to organisational factors (e.g. high workloads that constrain the behaviours of healthcare staff, burnout), and the relationship between carers and patients. Conclusion A social psychology-based conceptual model is developed to explain the occurrence and nature of patient neglect. This model will facilitate investigations of i) differences between patients and healthcare staff in how they perceive neglect, ii) the association with patient neglect and health outcomes, iii) the relative importance of system and organisational factors in causing neglect, and iv) the design of interventions and health policy to reduce patient neglect.
    BMC Health Services Research 04/2013; 13(1):156. DOI:10.1186/1472-6963-13-156 · 1.71 Impact Factor
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