|Year : 2008 | Volume
| Issue : 5 | Page : 491
Performance of ICUs
Editor, IJA, India
|Date of Web Publication||19-Mar-2010|
Source of Support: None, Conflict of Interest: None
|How to cite this article:|
Bajaj P. Performance of ICUs. Indian J Anaesth 2008;52:491
The performance of an intensive care unit (ICU) has different aspects. For many years ICU performance was synonymous with standard mortality ratio (SMR). Nowadays, however, other aspects of performance are taken into account, which are concerned with the patients', families', nurses', doctors' and providers' points of view. Several studies, on the other hand, have demonstrated the relationship between organisation and performance. Improving ICU performance requires that we shift from a paradigm that concentrates on individual performance to a different paradigm that emphasises the need to 'assess and improve ICU systems and processes.
Assessing performance requires the quantification of parameters that are relevant to patients, society and the hospital. For example, nosocomial infections are common and deadly complications of ICU care. Effective hand hygiene has a proven role in reducing nosocomial infections  , so that the rate at which ICU personnel perform recommended hand hygiene is an appropriate secondary index of ICU performance. The ICU readmission rate is a questionable indicator of ICU performance. For readmission to be a meaningful indicator would require that a detrimental outcome that occurred after the patient left was due to a problem present prior to the original ICU discharge and would not have occurred had the patient remained longer in the ICU  . Although daily costs are reduced by transferring patients from the ICU to ward beds, premature transfers lead to worse outcomes. Reductions in the lengths of stay and short-term mortality rates may merely reflect a shift of the place of death from one location to another, with no real net improvements. Thus, using short-term mortality rate or length of stay as outcomes can lead to erroneous conclusions  . The collection of data on post-hospital survival and QOL(quality of life) is laborious, which undoubtedly contributes to the low usage of these important measures. Combining these into a measure of long-term survival that is adjusted for the QOL, such as quality-adjusted life-years, is even more labour intensive. A variety of questionnaire-based tools have been developed for quantifying patients' QOL. The most commonly used is the Medical Outcomes Study 36-item short form  . Complication and error rates are often used as measures of ICU performance. These are relevant because or" potential causal relationships of such adverse events with increased mortality, morbidity or costs  . Symptom control and end-of-life decision-making are important aspects of ICU care. There is much room for improvement in this area. Because ICU care is expensive, resource consumption should be part of the assessment of ICU performance at every institution. The best measure that balances simplicity and information content is length of stay in the ICU, although, this has limitations. Other measures whose acquisition requires a lot of effort include total monetary charges or costs, usage of various diagnostic and/or therapeutic procedures and the therapeutic intervention scoring system (TISS) score  . It is important for ICU beds to be used effectively, because they are an expensive and limited resource. In practice, ICU triage decisions are often inefficient, but they can be made more effective without adverse medical consequences  .
The importance of satisfaction among patients and their families as measures of ICU performance is highlighted by data  documenting that poor communication and dissatisfaction are common. The satisfaction of all those who work in an ICU is another key component of ICU performance. Job dissatisfaction contributes to higher rates of staff turnover  . One large class of performance measures quantifies the processes, procedures and functions going on within the ICU or linking the ICU to the rest of the hospital, may be classified as structures(particularly management), processes(such as appropriateness of medical intervention) and outcomes (not only SMR, but also quality of life and family and staff satisfaction).
The SMR is the comparison between the probable hospital mortality (P) and the observed hospital mortality (O). The probability of mortality is estimated by a model using a severity score , . This approach is valid only when used with models characterised by excellent calibration and discrimination  . The recently devised scores are objective, built up from logistic regression. In their order of publication, they are APACHE III  , SAPS(Simplified Acute Physiology Score) II  and MPM II  .
The points of view of dying and surviving patients are obviously different. With reference to dying patients many studies have been published about the management of death in ICUs. A book edited by Curtis and Rubenfield, entitled "Managing death in the Intensive Care Unit, the transition from cure to comfort", has recently been published. What is important for surviving patients is the quality of life. Among the numerous papers devoted to this subject, we may quote the article published by Herridge et al . Looking at the 1-year outcomes of ARDS survivors, they found that 40 (49%) of 82, 1-year survivors had returned to work. Furthermore, of these 40 patients, 31 (78%) had returned to their original work. When, on the other hand, the authors considered the patients' ability to exercise and their health-related quality of life they found that at 1 year after ICU discharge 89% of survivors had normal physical functioning and 88% had a normal social functioning.
Many studies have been published on outcome for the patient's family. Let us quote a study by Azoulay et al on family members' desire to share in the decision making process. Poor comprehension was noted in 35% of family members. Among ICU staff members, 91% of physicians and 83% of non physicians believed that families should be offered the option of being involved in decision-making but that only 39% of patients had actually involved family members in decisions. A desire to share in decision-making was expressed by only 47% of family members, and only 15% of family members actually shared in decision-making. Effectiveness of information influenced this desire.
Nurses and the doctors working in ICUs may suffer from the burnout syndrome that reflects the exhaustion caused by the physical and psychological burdens their work entails. One study by Embriaco et al showed that 46.5% of 959 intensive care specialists interviewed at 1 day had high-degree burnout. Some of the risk factors for burnout found were: female sex, too many duties, too few holidays and conflicts between doctors or with nurses.
Good management makes for good performance. The first study published on this relationship was that by Shortell et a1 . Based on data collected from 17,440 patients across 42 ICUs, the 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. Findings revealed by the APACHE III methodology for risk adjustment were that: (1) technological availability is significantly associated with lower risk-adjusted mortality (beta = 0.42); (2) diagnostic diversity is significantly associated with greater risk-adjusted mortality (beta = 0.43); 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 = 0.34), lower nurse turnover (beta = 0.36), higher rated technical quality of care (beta = 0.81), and better rated ability to meet family members' needs (beta = 0.74). 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 who are taking an active part in hospital-wide quality improvement activities.
A French study conducted by Azoulay et at in 920 families showed the positive factors influencing patients' families' satisfaction. These were: family members of French descent, patient-to-nurse ratio < 3, information provided by junior physicians, and family helped by their usual doctor. The negative factors were: family feeling they received contradictory information, family not knowing the specific role of each caregiver, inadequate ratio of desired allowed time with the patient.
In the evaluation of an ICU's performance, the SMR is a necessary (but not sufficient) instrument. The SMR must be calculated from customised or expanded scores. The first 3 days in the ICU determine the outcome. The evaluation of performance must take account of the patients', families' and staff members' points of view. We must stress that good management makes for a well-performing unit.
| References|| |
|1.||Eggimann P, Pittet D. Infection control in the ICU. Chest 2001;120:2059-2209. [PUBMED] [FULLTEXT] |
|2.||Angus DC. Grappling with intensive care unit quality: does the readmission rate tell us anything? Crit Care Med 1998;26:1779-1780. [PUBMED] [FULLTEXT] |
|3.||Baker DW, Einstadter D, Thomas CL, et al. Mortality trends during a program that publicly reported hospital performance. Med Care 2002;40:879-890. [PUBMED] |
|4.||Ware JE, Snow KK, Kosinski M, et al. SF-36 health survey manual& interpretation guide. Health Institute, New England Medical Center, Boston, Mass 1993. |
|5.||Kohn LT, Corrigan JM, Donaldson MS (eds). To err is human. National Academies Press, Washington, DC 2000. |
|6.||Keene AR, Cullen DJ. Therapeutic Intervention Scoring System: update 1983. Crit Care Med 1983;11:1-3. [PUBMED] |
|7.||Strauss J, LoGerfo P, Yaltatzie JA, et al. Rationing of intensive care services: an everyday occurrence. JAMA 1986;255:1143-1146. |
|8.||Azoulay E, Chevret S, Leleu G, et al. Half the families of intensive care unit patients experience |
|9.||inadequate communication with physicians. Crit Care Med 2000;28:3044-3049. |
|10.||Steel RP, Ovalle NK. A review and meta-analysis of research on the relationship between behavioral intentions and employee turnover. J Appl Psychol 1984;69:673-686. |
|11.||Le Gall JR, Loirat P. Can we evaluate the performance of an Intensive Care Unit? Curr Opin Crit Care 1995;1:219-220. 11. Ridley S. Severity of illness scoring systems and performance appraisal. Anaesthesia 1998; 12:1185-1194. |
|12.||Lemeshow S, Le Gall IR. Modeling the severity of illness of ICU patients. A system update. JAMA 1994;272:1049-1055. |
|13.||Knaus WA, Drape EA, Wagner DP, et al. APACHE II: a severity of disease classification system. Crit Care Med 1985;13:819-829. |
|14.||Le Gall IR, Lemeshow S, Saulnier F. A new Simplified Acute Physiologic Score (SAPS II) based on an European/North American multicenter study. JAMA 1993;270:2957-2963. Correction: JAMA 271:1321. |
|15.||Lemeshow S, Teres D, Klar J, et al. Mortality Probability Models (MPM II) based on an international cohort of intensive care unit patients. JAMA 1993;270:2478-2486. [PUBMED] |
|16.||Herridge M, Cheung AM, Tansey CM, et al. One-year outcomes in survivors of the acute respiratory distress syndrome. N Engl J Med 2003;348:8. |
|17.||Azoulay E, Pochard F, Chevret S, et al. Half the family members of intensive care unit patients do not want to share in the decision making process: A study in 78 French intensive care units. Crit Care Med 2004;32:1832-1838. [PUBMED] [FULLTEXT] |
|18.||Embriaco N, Barrau K, Azoulay E, et al. Prevalence et facteurs de risque du burn out chez les reanimateurs francais. Reanimation 2005;14 [Suppl 1]:SOE 27. |
|19.||Shortell SR, Zimmerman JE, Gillies RR, et al. The performance of intensive care unit: does good management make a difference? Med Care 1994;32:508-525. |
|20.||Azoulay.E, Pochard F, Chevret S, et al. Meeting the needs of intensive care unit patients' families -a multicenter study. Am J Respir Crit Care Med 2001;163:135-139. |