Complex Environment of the Intensive Care Unit - Essay Example

Literature Review Intensive Care Unit or ICU is the most complex environment in any healthcare facility. Patients in ICU are those with or at high risk for life-threatening conditions and hence need specialized medical care consisting of constant monitoring and complex therapies and interventions. The extraordinary treatment is delivered by specially trained healthcare professionals with the use of high- tech environment. There are many challenges involved in an ICU setting. These include managing high- tech environment, ensuring adequate numbers of skilled and trained nursing staff, doctors and others health workers like physiotherapists and respiratory therapists, and providing high-quality care to the sickest patients. Along with these, meeting the needs of the staff members who work in a very stressful environment is also an important challenge. To provide high quality care in ICU, there is a need for interplay of high technology and high acuity in such a setting. This literature review concentrates on some of the important complexities involved in the management of critical care unit. Financial limitations Each year, more than 4 million US patients receive critical care and this costs more than $180 billion annually (ECRI Institute, 2007). 10 % of the in-patient beds are occupied by intensive care patients. 30% of acute care hospital costs accounts for intensive care. 8% of the hospital beds are occupied by those who need critical care (Society of Critical Care medicine Survey, 1991 and 1993; qtd in Brilli, Spevetz, & Branson, et al, 2001). Treatment in critical care is extremely expensive. It accounts for 20% of all hospital costs and 1% of the GDP (Luce & Rubenfeld, 2002). The reason why intensive care treatment is highly costly is that ICU is a resource- intense environment which requires skilled staff, costly and new drugs and expensive technology (Kahn & Angus, 2006). Most of the Americans are covered by a health insurance plan either through the companies they work for or through the employment of their spouse or parents. According to the Current Population Survey, 2004 (ASPE, 2005), 59.8% of the population are covered by employers and only 9% purchase insurance directly. Another important source of insurance is Government. Medicare is the largest public coverage program and covers 14% of the population. About 84% of the beneficiaries of Medicare are those above 65 years of age. Another insurance program is the Medicaid which covers 12.9% of the population. The population which is covered by this program constitutes mainly the children, pregnant women, elderly, and disabled people. Military/veterans coverage of insurance is also provided by the Government and this targets 4% (ASPE, 2005). It is not a problem for hospitals to take care of those with insurance coverage. But problem arises when the patient admitted does not have insurance coverage. Most of the uninsured are either poor or have a lower income. This is because; it is likely that these people do not have proper employment, or even if they work, it may not be a full time job that offers insurance coverage, or are not in a position to afford an offer of coverage (ASPE, 2005). Those who are not insured are mostly young. Infact, 21% of those who are not insured are less than 18 years of age and 63% of them are below 34 years of age. Institution of appropriate treatment is limited due to lack of funds in these patients. The cost of health care is rapidly increasing. Many researchers have studied various methods to reduce the high cost of intensive care treatment. Welch, Miller & Welch et al (1993) studied the geographic variation in the cost to treat critically ill patients and opined that a consensus was absent among various physicians dealing with ICU patients about the type services which are required. They proposed that health care to those who are critically ill can be improved by implementing protocols and treatment pathways. These methods also are supposed to increase efficiency and decrease costs to the patient. While some experts dismiss protocols as cook book medicine, many studies have proved that protocolized care reduces variation and improves outcome of critical care illness. Intensive care protocols can be set up for some aspects of management like analgesia, ventilation, liberation from ventilation, glycemic control and sedation (Holcomb, Wheeler & Ely, 2001). Another method to reduce variability and improve standards of critical care is by means of standardizing the way ICUs are managed and organized. Hanson, Deutschman, & Anderson, et al (1999) reported that creating a multidisciplinary team, with the team incharge being an intensivist and including nurses under the team would improve outcome and reduce the cost of hospitalisation. Thus it is obvious that reducing variability reduces cost. Usage of generic name of drugs instead of brands, fixed frequency of laboratory and radiological tests and specific indications for transfusions are some of the examples which help in reducing variation and indirectly reducing cost of care. Lack of skilled health care professionals Patients who are cared in critical care units are those with major head injury, severe trauma, coma, cardiorespiratory insufficiency, hemodynamic insufficiency, organ system failure and those who need monitoring following major surgery (ECRI Institute, 2007). It is obvious that patients admitted in ICUs require substantial nursing care. The staffing of the nurses is different from one ICU to the other. The optimal nurse-to-patient ratio is not very clear as yet. Decrease in this ratio to decrease cost to patient may affect quality of care. This aspect has not been well evaluated but has been a cause of concern to patients, providers, and policymakers. Various studies have infact associated specific complications such as pulmonary complications and postoperative infections to deficient nursing staff. Pronovost, Dang & Dorman (2001) evaluated the relationship between nurse-to-patient ratio in the critical care unit and the incidence of various complications, both surgical and medical, after abdominal aortic surgery. They reported that patients in hospitals with smaller nurse- to- patient ratio suffered from more number of complications. Close nursing surveillance is essential for early detection of potential adverse events in critically ill patients in an ICU. Early detection must lead to prompt intervention. Inadequate nursing staff affects the quality and outcomes of care negatively. Decreased nursing staff thus indirectly contributes to increased number of days in the hospital and also more medical expenditure. Lahaie (2004) demonstrated the administrative complexities faced by managers of health care in controlling expenditure and also managing critical care environment. He reported that “nursing professionals are caught in the squeeze between providing the service they are trained for, and their needs for appropriate compensation under conditions of increasing work pressure." Patient- doctor ratio is also an important aspect. This ratio is not constant across the world. The ratio is very high in the underdeveloped countries and is very low in the developed countries. This ratio indirectly depends on the number of medical colleges, government planning, infrastructure and lucrative opportunities following the completion of the course (Rahman, 2008). Risk for Complications Critically ill patients are at risk for complications due to the nature of their problems and also due to medications and interventions. Some of the common complications include ventilator associated pneumonias, central-vascular-catheter-associated bloodstream infection, pressure ulcers and complications due to medical and surgical procedures. The mortality rates in intensive care units can be as high as 10- 20% (Leapfrog Group, qtd. in ECRI Institute, 2007). Omission of certain therapies due to lack of knowledge in the attending intensivist or due to unavailability of the drugs or equipment also contributes to morbidity and mortality. Adverse events and errors It has been reported that adverse events in ICUs can occur and the estimated rate is 81 for every thousand patient- days. Serious errors are expected to occur, the rate being 150 for every 1,000 patient-days and half of these are deemed preventable (Critical Care Safety Study, 2005; qtd. in ECRI Institute, 2007). Common errors include errors in conducting procedures, errors in carrying out medication orders, errors in communicating or reporting clinical findings, failure to follow protocols and failure to take precautions. Errors occur not only due to carelessness on the part of staff and lack of knowledge, they also occur due to the complexity of the medical devices and technology. For example, intubation and mechanical ventilation is life- saving in a patient with respiratory failure. But tube dislodgement or tube block can occur and cause oxygen insufficiency. Equipments with clinical alarms, intravenous drug delivery systems, monitors and special care beds and mattresses can go wrong and contribute to errors if they are not used properly in good conditions and by properly trained staff. Safety regulations in ICU Each hospital has its own safety protocol. Having a culture that promotes and supports safety activities in an ICU is a key element in providing error- free and accident- free treatment for the patients. This can be enhanced by working collaboratively and communicating effectively. . Hospitals with intensivists in their ICUs usually have lesser rates of mortality and lesser duration of hospital stay when compared to those who do not house trained intensivists. Also, creating a healthy work environment with productive interaction, making vital decisions and performing medical interventions safely contribute to the safety of the patient. Since stress fatigue and distractions increase the likelihood of errors, mistakes and adverse events, adequate staffing and composed environment must be created in intensive care units. Rise of hospital acquired infections Research has shown that nosocomial infections not only increase the rate of mortality and morbidity in ICUs but also increase the costs. They also increase the duration of stay in the hospital and the frequency and duration of organ failures. Ylipalosaari and colleaugues (2006) demonstrated that infections acquired in ICU is a factor which with independent risk for mortality in the hospital. The risk was demonstrated by the researchers even after adjustment of SOFA and APACHE- II scores. These infections pose a major burden on the costs and outcomes of intensive care. However, these infections may not have any impact on the long term survival of the patient (Ylipalosaari and colleagues, 2007). Hospital- acquired infections can be prevented by following certain protocols and guidelines. In the U.S., Centers for Disease Control (CDC) as well as a variety of organizations have put forward many guidelines to limit nosocomial infections. Though these guidelines are simple to follow, high levels of compliance are difficult to achieve. Thus health care leaders must work very hard to achieve compliance. They must strive hard to educate, motivate and eliminate all types of barriers in order to adopt these routine practices everyday to prevent hospital -acquired infections. Such a commitment undoubtedly makes a significant difference in reducing the rate of hospital acquired infections. The fundamental and the most important practice in the prevention of these infections is proper hand hygiene since most of the times infections are transmitted through contaminated hands of the health workers. Compliance can be further enhanced by dispensing sanitizing hands products easily at a variety of locations. CDC guidelines recommend washing hands with an alcohol-based rub both before and after contact with each patient (Cherry, 2008). Along with these measures, using gloves during patient care also helps reduce transmission of infectious agents to patients. These gloves must be disposed off appropriately immediately after the purpose is served. While placing transcutaneous, indwelling devices such as chest tubes and central lines, health care workers must apply full barrier sterile precautions as per the recommendations of the CDC. These precautions include wearing mask and cap, sterile gloves, sterile gown and applying a large area of drape around the working field. Chlorhexidine preparation is supposed to be more efficacious than betadine preparation (Cherry, 2008). Conclusion There are many complexities involved in delivering efficient care in an intensive care unit. The most important factor is financial condition of the patient. Since most of the patients in the US are covered by insurance, this factor is a limitation for treatment mainly to those without insurance coverage. Intensive care costs can be reduced by following certain protocols. The next important complexity is skilled staff. Other factors which affect proper ICU management are stress and fatigue of the staff, attitude of the management, rise in hospital- acquired infections and adverse events and errors. References ASPE, U.S. Department of Health and Human Services (2005). Overview of the Uninsured in the United States: An analysis of the 2005 Current Population Survey. Retrieved on 8th January 2009 from http://aspe.hhs.gov/health/reports/05/uninsured-cps/index.htm Brilli, R.J., Spevetz, A., & Branson, R.D., et al (2001). Critical care delivery in the intensive care unit: Defining clinical roles and the best practice model. Critical Care Medicine, 29(10), pgs. 2006- 2009. Cherry, T. (2008). Best practices in reducing hospital-acquired infections. The Medguru. Retrieved on 8th January 2009 from http://www.themedguru.com/articles/best_practices_in_reducing_hospital_acquired_infections-86111957.html ECRI Institute. (2007). Critical Care Safety: Essentials for ICU Patient Care and Technology. Retrieved on 8th January 2009 from https://www.ecri.org/Documents/CriticalCare_TOC.pdf. Hanson, C.W., Deutschman, C.S., Anderson, H.L., et al (1999). Effects of an organized critical care service on outcomes and resource utilization: a cohort study. Crit Care Med., 27(2), pp.270-4 Holcomb, B.W., Wheeler, A.P., Ely, E.W. (2001). New ways to reduce unnecessary variation and improve outcomes in theintensive care unit. Current Opinion in Critical Care, 7, pp. 304- 311. Kahn, J.M., & Angus, D.C. (2006). Reducing the Cost of Critical Care: New Challenges, New Solutions. American Journal of Respiratory and Critical Care Medicine, 174, pp. 1167-1168. Lahaie, D.S. (2004). Financial challenges and complexity in the management of an intensive care/coronary care unit: a case study. Leadership in Health Services, 17(2), pp. 9-16. Luce, J.M., & Rubenfeld, G.D. (2002). Can Health Care Costs Be Reduced by Limiting Intensive Care at the End of Life? Am. J. Respir. Crit. 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Intensive care unit acquired infectio has no impact on long term survival or quality of life: a prospective cohort study. Critical Care, 11, Retrieved on 8th January 2009 from http://ccforum.com/content/11/2/R35 Read More