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A new way of managing critical care?

In the United Kingdom, critical care is a labour-intensive, high-cost system for looking after the sickest hospital patients. There are inadequate numbers of beds for present demand and the need is likely to increase substantially. The Government plans to increase healthcare funding significantly over the next few years. However, even where money is available it often proves difficult or impossible to expand critical care provision because of the shortage of trained intensive care unit (ICU) nurses. Once admitted to a critical care unit, patients receive excellent care, however, hospital patients often receive suboptimal care before ICU admission. Pressure on ICU beds means that patients may be refused admission or prematurely discharged; this is associated with increased mortality. It is important to balance the needs of those admitted to a critical care area with those who are refused admission or are discharged inappropriately early. If more patients could be treated without increasing morbidity and mortality it might be worth considering a different way of delivering critical care services. The nurse-patient ratio in an ICU (level 3) unit is typically 1 : 1. This requires approximately 6.5 nurses to be employed for each ICU bed, although in practice this varies widely. HighDependency beds (level 2) are usually run at a lower nurse-patient ratio, typically 1 : 2. Nurses’ salaries is the largest single cost at some £140 000 per annum per ICU bed and 45% of the total budget. Costs are further increased where agency nurses are employed or there is a high turnover of staff. The nurse-patient ratio varies widely within Europe. In one study, based on a relatively small amount of information, the United Kingdom was the least efficient in terms of work delivered by nursing staff employed. In the United States, the nurse-patient ratio is commonly 1 : 2 or 1 : 3. This may, at least in part, be accounted for by differences in case mix and by the provision of additional non–nurse support staff. There is some evidence to show that lower nurse-patient ratios and organisational factors may be associated with a higher incidence of complications. However, global outcome measures do not seem to be noticeably worse in systems with fewer nurses per patient. A rigid nurse-patient ratio does not allow flexibility to respond to changes in patient management and technology. For example, new renal haemofiltration machines take 20 min to set up compared to 2 h for older machines. Mechanical beds can be programmed to turn patients routinely. Drugs can be supplied by pharmacy preprepared in ready-to-use syringes. Automatic charting is now feasible and drug delivery systems and alarms more sophisticated and reliable. Closed circuit cameras can be used to monitor isolated patients. Changes such as these have the potential to relieve nurses of some of their work. It may be possible to organise nurses in a more task-orientated manner focusing on the needs of all patients within the Unit rather than the requirement to have a nurse by each bedside. For example, by changing practice would it be possible to lower the nurse-patient ratio at night? Even if a high nurse-patient ratio is desirable, the shortage of trained nurses now, and in the future, make it necessary to examine other ways of delivering critical care. One hypothesis that might be worth examining is whether capital investment and alternative ways of working would allow an ICU to be run with fewer nurses per bed while still delivering an acceptable standard of care. Within the same budget, substantially reducing the number of nurses would free money for capital investment and for a significant salary increase for the remaining nurses. Alternatively, a relatively modest capital investment could be used to increase the number of critical care beds with the same number of nursing staff. This hypothesis could be explored in the following way, 1 Review the evidence on the cost of intensive care nursing in the United Kingdom 2 Commission a demographic study to identify the likely future provision of trained critical care nurses 3 Review the evidence on nurse-patient ratios in critical care units in Europe and North America 4 Review the evidence on the effect of nurse-patient ratios on outcome 5 Commission a study looking at working practices in Europe and North America in successful units with a nurse-patient ratio of less than 1 : 1 6 Commission a time and motion study in British critical care units with the aim of identifying nursing work that could be automated, delegated or omitted 7 If the studies support the feasibility of changing ICU practice, invest in a showcase pilot ICU based on this work. At this stage it is essential to emphasise that the exercise is NOT about saving money but capital investment to ensure that the skilled, scarce and expensive nurses are used in the most cost effective way. It would be appropriate to reward nurses who took on this changed role with a substantial salary increase to reflect their increased productivity. Is this hypothesis complete nonsense? Possibly. However, within the monolithic and rigid structure that is the National Health Service there ought to be opportunities to explore new ways of working. The problem of underprovision and lack of trained staff will not easily go away. The hypothesis above is probably not the best solution and is certainly not the only one. If you have a better idea please make it known. Anaesthesia, 2002, 57, pages 843–844 .