2 Resourcing Critical Care
After reading this chapter, you should be able to:
• describe historical influences on the development of critical care and the way this resource is currently viewed and used
• explain the organisational arrangements and interfaces that may be established to govern a critical care unit
• identify external resources and supports that assist in the governance and management of a critical care unit
• describe considerations in planning for the physical design and equipment requirements of a critical care unit
• describe the human resource requirements, supports and training necessary to ensure a safe and appropriate workforce
• explain common risks and the appropriate strategies, policies and contingencies necessary to support staff and patient safety
• discuss leadership and management principles that influence the quality, efficacy and appropriateness of the critical care unit
• discuss common considerations from a critical care perspective in responding to the threat of a pandemic.
Introduction
In 1966 Dr B Galbally, a hospital resuscitation officer at St Vincent’s Hospital, Melbourne, published the first article on the planning and organisation of an intensive care unit (ICU) in Australia.1 He identified that critically ill patients who have a reasonable chance of recovery require life-saving treatments and constant nursing and medical care, but this intensity of service delivery ‘does not necessarily continue until the patient dies, and it should not continue after the patient is considered no longer recoverable’.1
The need for prudent and rational allocation of limited financial and human resources was as important for Australia’s first ICU (St Vincent’s, Melbourne, 1961) as it is for the 200 or more now scattered across Australia and New Zealand. This chapter explores the influences on the development of critical care and the way this resource is currently viewed and used; describes various organisational, staffing and training arrangements that need to be in place; considers the planning, design and equipment needs of a critical care unit; covers other aspects of resource management including the budget; and finishes with a description of how critical care staff may respond to a pandemic. First, however, important ethical decisions in managing the resources of a critical care unit, which are just as important as the ethical resources that govern the care decisions for an individual patient (see Chapter 6), are discussed below.
Ethical Allocation and Utilisation of Resources
At the other extreme is the utilitarian view, which suggests an action is right only if it achieves the greatest good for the greatest number of people. This concept tends to sit well with pragmatic managers and policy makers.2 An example of a utilitarian view might be to ration funding allocated to heart transplantation and to utilise any saved money for prevention and awareness campaigns. A heart disease prevention campaign lends a greater benefit to a greater number in the population than does one transplant procedure.
Historical Influences
An often-held view is that managers in government health services have no incentive to spend or expand services.3 However, the opposite is probably true. Developing larger and more sophisticated services such as ICUs can attract media and public attention. The 1960s and early 1970s saw the development of the first critical care units in Australia and New Zealand. If a hospital was to be relevant, it had to have one. In fact, what distinguished a tertiary referral teaching hospital from other hospitals was, at its fundamental conclusion, the existence of a critical care unit.4 Over time, practical reasons for establishing critical care units have led to their spread to most acute hospitals with more than 100 beds. Reasons for the proliferation of critical care services include, but are not limited to:
• economies of scale by cohorting critically ill patients to one area
• development of expertise in doctors and nurses who specialise in the care and treatment of critically ill patients
• an ever-growing body of research demonstrating that critically ill patient outcomes are better if patients are cared for in a specifically equipped and staffed critical care unit.4
Funding for critical care services has evolved over time to be somewhat separate from mainstream patient funding, owing to the unique requirements of critical care units. Critical care is unique because patients are at the severe end of the disease spectrum. For instance, the funding provided for a patient admitted for chronic obstructive airway disease in an ICU on a ventilator is very different from that provided for a patient with the same diagnosis, but treated only in a medical ward. Each jurisdictional health department tends to create its own unique approach to funding ICU services in its jurisdiction.5 For instance, Queensland tends to fund ICU patients who are specifically identified and defined in the Clinical Services Capability Framework for Intensive Care6 with a prescribed price per diem, depending on the level of intensive care given to the patient or a price per weighted activity unit, as defined in the business rules and updated on an annual basis.7 In Victoria, the diagnosis-related group (DRG) payment for individual patient types admitted to the hospital also pays for ICU episodes, with some co-payment elements added for mechanical ventilation.8 In New South Wales a per diem rate is established for ICU patients, while high-dependency patients in ICU are funded through the hospital DRG payment; in South Australia a flat per diem rate exists.9,10 Most other states have a global ICU budget payment system based on funded beds or expected occupied bed days in the ICU. However, within states and specific health services and hospitals the actual allocation of funding to the ICU may vary, depending on the nature of the specific ICU and demands and priorities of the health service.11
The RAND study12 examined funding methods in many countries and concluded that there was no obvious example of ‘best practice’ or a dominant approach used by a majority of systems. Each approach had advantages and disadvantages, particularly in relation to the financial risk involved in providing intensive care. While the risk of underfunding intensive care may be highest in systems that apply DRGs to the entire episode of hospital care, including intensive care, concerns about potential underfunding were voiced in all systems reviewed. Arrangements for additional funding in the form of co-payments or surcharges may reduce the risk of underfunding. However, these approaches also face the difficulty of determining the appropriate level.12
At the hospital level, most critical care units have capped and finite budgets that are linked to ‘open beds’ – that is, beds that are equipped, staffed and ready to be occupied by a patient, regardless of whether they are actually occupied.13 This is one crude yet common way that hospitals can control costs emanating from the critical care unit. The other method is to limit the number of trained and experienced nurses available to the specialty; consequently, a shortage of qualified critical care nurses results in a shortage of critical care beds, resulting in a rationing of the service available. The capping of beds and qualified critical care nurse positions can be convenient mechanisms to limit access and utilisation of this expensive service – critical care.
Economic Considerations and Principles
One early comprehensive study of costs found that 8% of patients admitted to the ICU consumed 50% of resources but had a mortality rate of 70%, while 41% of patients received no acute interventions and consumed only 10% of resources.14 More recent Australian studies show that, although critical care service is increasingly being provided to patients with a higher severity of acute and chronic illnesses, long-term survival outcome has improved with time, suggesting that critical care service may still be cost-effective despite the changes in case-mix.15,16
An Australian study showed that in 2002, ICU patients cost around $2670 per day or $9852 per ICU admission, with more than two-thirds going to staff costs, one-fifth to clinical consumables and the rest to clinical support and capital expenditure.17 Nevertheless, some authors provide scenarios as examples of poor economic decision making in critical care and argue for less extreme variances in the types of patient ICUs choose to treat in order to reduce the burden of the health dollar.18,19 Others have suggested that if all healthcare provided were appropriate, rationing would not be required.3 Defining what is ‘appropriate’ can be subjective, although not always. The RAND12,20 group suggests that there are at least three approaches that can be used to assess appropriateness of care (Table 2.1). These include the benefit–risk, benefit–cost and implicit approaches.
Approach | Description |
---|---|
Benefit–risk approach | The benefit of treatment and the inherent risks to the patient are assessed to inform a decision; this approach excludes monetary costs. |
Benefit–cost approach | Evaluate the benefit and cost of the decision to proceed; this approach incorporates cost to patient and society. |
Implicit approach | The medical practitioner provides the service and judges its appropriateness. |
The quality of the outcome is a function of the benefit to be achieved and the sustainability of the benefit. The benefit of critical care is associated with such factors as survival, longevity and improved quality of life (e.g. greater functioning capacity and less pain and anxiety). The benefit is enhanced by sustainability: the longer the benefit is maintained, the better it is.21
Cost is separated into two components, monetary (price) and non-monetary (suffering). Non-monetary costs include such considerations as morbidity, mortality, pain and anxiety in the individual, or broader societal costs and suffering (e.g. opportunity costs to others who might have used the resources but for the current occupants, and what other health services might have been provided but for the cost of this service).21
Ethico-economic analyses of services like critical care and expensive treatments like organ transplantation are the new consideration of this century and are as important to good governance as are discussions of medico-legal considerations. Sound ethical principles to inform and guide human and material resource management and budgets ought to prevail in the management of critical care resources.2
Budget
This section provides information on types of budget, the budgeting process, and how to analyse costs and expenditure to ensure that resources are utilised appropriately. As noted by one author, ‘Nothing is so terrifying for clinicians accustomed to daily issues of life and death as to be given responsibility for the financial affairs of their hospital division!’.3 Yet, in essence, developing and managing a budget for a critical care unit follows many of the same principles as managing a family budget. Consideration of value for money, prioritising needs and wants, and living within a relatively fixed income is common to all. This section in no way undermines the skill and precision provided by the accounting profession, nor will it enable clinicians to usurp the role of hospital business managers. Rather, the aim is to provide the requisite knowledge to empower clinicians to manage the key components of budget development and budget setting, and to know what questions to ask when confronted by this most daunting responsibility of managing a unit’s or service’s budget.
Types of Budget
Personnel Budget
Personnel budgets tend to be fixed costs, in that the majority of staff are employed permanently, based on an expected or forecast demand. Prudent managers tend to employ 5–10% less than the actual forecast demand and use casual staff to ‘flex-up’ the available FTE staff establishment in periods of increasing demand, hence contributing a small but variable component to the personnel budget.22
Budget Process
Budget Analysis and Reporting
Most critical care managers analyse their expenditure against budget projections on a monthly basis, to identify variances from planned expenditure. Information should not merely be financial: a breakdown of the monthly and year-to-date expenditures for personnel (productive and non-productive), and operational (fixed and variable) costs, should be matched against other known measurable indicators of activity or productivity (e.g. patient bed-days, patient types/DRGs and staffing hours, including overtime and other special payments).3
Budget Control and Action
When signs of poor performance or financial overrun are evident, managers cannot merely analyse the financial reports, hoping that things will sort themselves out. Every variance of a sizeable amount requires an explanation. Some will be obvious: an outbreak of community influenza among staff will increase sick leave and casual staff costs for a period of time. Other overruns can be insidious but no less important: overtime payments, although sometimes unavoidable, can also reflect poor time management or a culture of some staff wanting to boost their income surreptitiously.22
Developing A Business Case
The most common reason for writing a business case is to justify the resources and capital expenditure to gain the support and/or approval for a change in service provision and/or purchase of a significant new piece of equipment/technology. This section provides an overview of a business case and a format for its presentation. The business case can be an invaluable tool in the strategic decision-making process, particularly in an environment of constrained resources.23
A business case is a management tool that is used in the process of meeting the overall strategic plan of an organisation. Within a setting such as healthcare, the business case is required to outline clearly the clinical need and implications to be understood by leaders. Financial imperatives, such as return on investment, must also be defined and identified.23–25 A business case is a document in which all the facts relevant to the case are documented and linked cohesively. Various templates are available (see Online Resources) to assist with the layout. key questions are generally the starting point for the response to a business case: why, what, when, where and how, with each question’s response adding additional information to the process (Table 2.2). Business cases can vary in length from many pages to just a couple. Most organisations will have standardised headings and formats for the presentation of these documents. If the document is lengthy, the inclusion of an executive summary is recommended, to summarise the salient points of the business case (Box 2.1).
Question | Example |
---|---|
Why? | What is the background to the project, and why is it needed: PEST (political, economic, sociological, technological) and SWOT (strengths, weaknesses, opportunities and threats) analysis? |
What? | Clearly identify and define the project and the purpose of the business case and outline the solution. Clearly defined, measurable benefits should be documented; goals and outcomes. |
What if? | A risk assessment of the current situation, including any controls currently in place to address/mitigate the issue, and a risk assessment following the implementation of the proposed solution. |
When? | What are the timelines for the implementation and achievement of the project/solution? |
Where? | What is the context within which the project will be undertaken, if not already included in the background material? |
How? | How much money, people and equipment, for example, will be required to achieve the benefits? A clear cost–benefit analysis should be included in response to this question. |
Critical Care Environment
A critical care unit is a distinct unit within a hospital that has easy access to the emergency department, operating theatre and medical imaging. It provides care to patients with a life-threatening illness or injury and concentrates the clinical expertise and technological and therapeutic resources required.26 The College of Intensive Care Medicine (CICM) defines three levels of intensive care to support the role delineation of a particular hospital, dependent upon staffing expertise, facilities and support services.27 Critical care facilities vary in nature and extent between hospitals and are dependent on the operational policies of each individual facility. In smaller facilities, the broad spectrum of critical care may be provided in combined units (intensive care, high-dependency, coronary care) to improve flexibility and aid the efficient use of available resources.26
Organisational Design
The functional organisational and unit designs are governed by available finances, an operational brief and the building and design standards of the state or country in which the hospital is located. A critical care unit should have access to minimum support facilities, which include staff station, clean utility, dirty utility, store room(s), education and teaching space, staff amenities, patients’ ensuites, patients’ bathroom, linen storage, disposal room, sub-pathology area and offices. Most notably, the actual bed space/care area for patients needs to be well designed.26
The design of the patient’s bed-space has received considerable attention in the past few years. In Australia, most state governments have developed minimum guidelines to assist in the design process. Each bed space should be a minimum of 20 square metres and provide for visual privacy from casual observation. At least one handbasin per single room or per two beds should be provided to meet minimum infection control guidelines.26 Each bed space should have piped medical gases (oxygen and air), suction, adequate electrical outlets (essential and non-essential), data points and task lighting sufficient for use during the performance of bedside procedures. Further detailed descriptions are available in various health department documents.26
Equipment
Initial Set-Up Requirements
Critical care units require baseline equipment that allows the unit to deliver safe and effective patient care. The list of specific equipment required by each individual unit will be governed by the scope of that unit’s function. For example, a unit that provides care to patients after neurosurgery will require the ability to monitor intracranial pressure. Table 2.3 lists the basic equipment requirements for a critical care unit.
Monitoring | Therapeutic |
---|---|
CT = computerised tomography; CVVHDF = continuous veno-venous haemodiafiltration; EDD-f = extended daily dialysis filtration; MRI = magnetic resonance imaging; PiCCO = pulse-induced contour cardiac output.
Purchasing
The procurement of any equipment or medical device requires a rigorous process of selection and evaluation. This process should be designed to select functional, reliable products that are safe, cost-effective and environmentally conscious and that promote quality of care while avoiding duplication or rapid obsolescence.28 In most healthcare facilities, a product evaluation committee exists to support this process, but if this is not the case it is strongly recommended that a multidisciplinary committee be set up, particularly when considering the purchase of equipment requiring capital expenditure.29
The product evaluation committee should include members who have an interest in the equipment being considered and should comprise, for example, biomedical engineers and representatives from the central sterile supply unit (CSSU), administration, infection control, end users and other departments that may have similar needs. Once a product evaluation committee has been established, clear, objective criteria for the evaluation of the product should be determined (Box 2.2). Ideally, the committee will screen products and medical devices before a clinical evaluation is conducted to establish its viability, thus avoiding any unnecessary expenditure in time and money.28
Box 2.2
Example criteria for product evaluation28,29
Staff
Staffing Roles
There are a number of different nursing roles in the ICU nursing team, and various guidelines determine the requirements of these roles. Both the Australian College of Critical Care Nurses (ACCCN) (see Appendix B2) and the World Federation of Critical Care Nurses (WFCCN) (see Appendix A2) have position statements surrounding the critical care workforce and staffing. A designated nursing manager (nursing unit manager/clinical nurse consultant/nurse practice coordinator/clinical nurse manager, or equivalent title) is required for each unit to direct and guide clinical practice. The nurse manager must possess a post-registration qualification in critical care or in the clinical specialty of the unit.27,30 A clinical nurse educator (CNE) should be available in each unit. The ACCCN recommends a minimum ratio of one full-time equivalent (FTE) CNE for every 50 nurses on the roster, to provide unit-based education and staff development.27,30 The clinical nurse consultant (CNC) role is utilised at the unit, hospital and area health service level to provide resources, education and leadership.30 Registered nurses within the unit are generally nurses with formal critical care postgraduate qualifications and varying levels of critical care experience.
Prior to the mid-1990s, when specialist critical care nurse education moved into the tertiary education sector, critical care education took the form of hospital-based certificates.31 Since this move, postgraduate, university-based programs at the graduate certificate or postgraduate diploma level are now available, although some hospital-based courses that articulate to formal university programs continue to be accessible. The ACCCN (see Appendix B1) and the WFCCN (see Appendix A1) have developed position statements on the provision of critical care nursing education. Various support staff are also required to ensure the efficient functioning of the department, including, but not limited to, administrative/clerical staff, domestic/ward assistant staff and biomedical engineering staff.
Staffing Levels
The starting point for most units in the establishment of minimum, or base, staffing levels is the patient census approach. This approach uses the number and classification (ICU or HDU) of patients within the unit to determine the number of nurses required to be rostered on duty on any given shift. In Australia and New Zealand a registered nurse-to-patient ratio of 1 : 1 for ICU patients and 1 : 2 for high-dependency unit (HDU) patients has been accepted for many years. Recently in Australia there have been several projects examining the use of endorsed enrolled nurses (EEN) in the critical care setting. The New South Wales project identified difficulties with EENs undertaking direct patient care, but determined that there may be a role for them in providing support and assistance to the RN.27,30,32 Other countries, such as the USA, have lower nurse staffing levels, but in those countries nursing staff is augmented by other types of clinical or support staff, such as respiratory technicians.33 The limitations of this staffing approach are discussed later in this chapter. Once the base staffing numbers per shift have been established, the unit manager is required to calculate the number of full-time equivalents that are required to implement the roster. In Australia, one FTE is equal to a 38-hour working week.