Health Services Research applied inHealth Services Research applied inthe ICU as experimental modelthe ICU as experimental model

Health Services Research applied inHealth Services Research applied inthe ICU as experimental modelthe ICU as experimental model

The EURICUS projectThe EURICUS projectThe EURICUS projectThe EURICUS projectEUROPEAN ICU STUDIES

The Effectiveness and Efficiency of Health CareThe Effectiveness and Efficiency of Health Care

Management

Process

of Care

Effectiveness

Efficiency

INPUTINPUT THROUGHPUTTHROUGHPUT OUTPUTOUTPUT

European ICUEuropean ICU studiesstudies = = Project-Project-ModelModelEuropean ICUEuropean ICU studiesstudies = = Project-Project-ModelModel

Budgeting

Objectives ICU

case-mix, etc.

Costsintermediateoutput

University CentersUniversity Centers

Groningen, NLUniversity HospitalSchool of ManagementEpidemiology

Utrecht, NLPsychology

FU Brussels, BEconomics

Health Services ResearchOrg. Techn. & Innovation

Statistics & Methodology

Social and Organizational Psychology

DepartmentDepartment LeadersLeaders

Prof. Dr. D. Reis MirandaProf. Dr. W. van Rossum andProf. Dr. G. SandersDr. V. Fidler

Prof. Dr. W. Schaufeli

Micro EconomicsWork organization andEconomic psychology

Prof. Dr. M. JegersProf. Dr. R. Pepermans

EURICUS-IEURICUS-IEURICUS-IEURICUS-I

• 89 ICUs - 12 European countries89 ICUs - 12 European countries• 2,200 Nurses2,200 Nurses• 750 Physicians750 Physicians• 16,000 Patients16,000 Patients• 76,000 nursing days76,000 nursing days• Site VisitsSite Visits

SURVEY

4 Sub-studies: Patients & facilities Organization Personnel Culture Finances

The effect of variables of (non-clinical) organization and management on performance

EURICUS-IIEURICUS-IIEURICUS-IIEURICUS-II

• 44 ICUs - 10 European countries44 ICUs - 10 European countries• 1,200 Nurses1,200 Nurses• 450 Physicians450 Physicians• 20,000 Patients20,000 Patients• 100,000 nursing days100,000 nursing days• Site Visits + FilmingSite Visits + Filming

R.C.T.R.C.T.

-Randomisation-Training-Use of Protocols-Outcomes of Care-Out. of Human Resources

The effect of collaborative practice on performance

Collaborative practice

+ +

OSF Mortality+

-

Adverse events

INTERVENTIONINTERVENTION

for improving collaborative practice

TRAINING to nursing and physiciansTRAINING to nursing and physicians

• How do we communicate? • Conversation techniques• Cooperation as a team

2 PROTOCOLS2 PROTOCOLS• Process awareness: hourly check of monitoring, and decision-tree

to consult physician

• Building mutual respect:nurses and physicians discuss professionally

Collaborative Practice was assessed with questionnaires (3X)Collaborative Practice was assessed with questionnaires (3X)

QUESTIONNAIRESQUESTIONNAIRES

SCALESSCALES VARIABLESVARIABLESQuality of communication Perceived openness Accuracy TimelinessProblem solving Co-operationCollaborative practice Trust Equality Participation Giving opinion Role clarificationSatisfaction with communication Nurses and others Physicians and others Nurses and physiciansJob demands Job demandsDecision latitude Decision latitude

EURICUS-IIIEURICUS-IIIEURICUS-IIIEURICUS-III

R.C.T.R.C.T.

• 45 ICUs - 10 European countries45 ICUs - 10 European countries• 89 ICU leaders89 ICU leaders• 9,300 patients9,300 patients• 54,000 nursing days54,000 nursing days

- Case Mix- Use of Guidelines & Protocols, for- Budgeting &- Direct Costing- Economic Environment ICU managers

Budgeting and Costing

• One day training on Budgeting and CostingOne day training on Budgeting and Costing• Software for calculations and ‘scenarios’Software for calculations and ‘scenarios’• Daily collection of costing dataDaily collection of costing data

EURICUS-IIIEURICUS-III

INTERVENTIONINTERVENTION

Category

- Labour

- Med Equipment

- Blood products

- Clinical Services

Laboratory

Radiology

- Disposables

-Non-clinical Serv.

Administration, etc

- Non-med. Equip.

- Pharmaceuticals

- Total cost

Annual BudgetAnnual Budget Direct costingDirect costing

Real-timeReal-timemeasurementmeasurementof activitiesof activities

at patient levelat patient level

24 hr checks on variable cost items

1) Blood (units)1-3 4-10 >10

2) Blood products (units)1-3 4-10 >10

3) SedativesBenzodyazepins Opiates Other

4) Antibiotics (IV)Cefalosporins Antifungics Antiviral

5) IV FeedingPN

6) LaboratorySTAT Biochemistry Bacteriology Other

7) Blood Gas Analysis1-3 4-10 >10

8) Radiology procedures>1 chest X-ray Ultrasound Other

9) NEMS-score

RESULTS

Insufficient OMInsufficient OM

WASTE OF RESOURCESWASTE OF RESOURCES

• Mismatch in 75% of ICU

• 30% of resources not used30% of resources not used- beds (Occupancy Rate)- nurses (WUR)

EURICUS-I

Due to predominant surgical activities:

daily and weeklydaily and weeklyunfavourableunfavourable

patterns of turnoverpatterns of turnover

0 5 10 15 20 %%

Mo

Tu

We

Th

Fr

Sa

Su

Discharge Admission

Pattern of weekly turnover of short stay patients

EURICUS I

0 5 10 15 20 25 30 35 40 %%

Discharge Admission

Pattern of daily turnover of short stay patients

0 - 2

2 - 4

4 - 6

6 - 8

8 - 10

10 - 12

12 - 14

14 - 16

16 - 18

18 - 20

20 - 22

22 - 24

HoursEURICUS I

Hidden misuse of resourcesHidden misuse of resources

ICU NURSING STAFFICU NURSING STAFF

examples

# FTE’s/bedBelgium 2.4France 2.6Italy 3.2Spain 3.4The Netherlands 4.1United Kingdom 5.0Norway 8-10

All countries reported shortage of nurses, beds closed,All countries reported shortage of nurses, beds closed,unnecessary death of patientsunnecessary death of patients

P/N<1.5

P/N>1.5

p

Number 66 48

P/N ratio 1.1+.26 2.8+5.2 .000

Case-mixSAPS II 34.6+6.3 34.1+5.4 NS

Outcome of Care

Mortality 20.1+8.6 17.2+9.0 NS

SMR 1.07+.47 .95+.27 NS

SOFA 5.1+1.7 4.7+1.3 NS

Outcome of OM

OR 72.5+18.5 69.6+17.3 NS

WUR .62+.24 .86+.26 .000

LOS 2.7+2.8 3.7+3.7 NS

EURICUS Database – ICU vs. ‘HDU’

EURICUS studiesEURICUS studies has shown

In the ICUs, the processes of workIn the ICUs, the processes of worknever have been analyzednever have been analyzed

Among ICUs, the chance of dyingAmong ICUs, the chance of dyingcould vary up to a factor 6could vary up to a factor 6

There are no “standardized” standards of careThere are no “standardized” standards of careamong ICUsamong ICUs

The way of work lacks structure

EURICUS studiesEURICUS studies has shown

Budgeting and costing procedures areBudgeting and costing procedures aresystematically lacking or underdevelopedsystematically lacking or underdeveloped

At least 50% of the costs correspond toAt least 50% of the costs correspond toactivities of care that are registered dailyactivities of care that are registered dailyfor clinical purposesfor clinical purposes

The same medical interventions may costThe same medical interventions may costsignificantly different across ICUs, with thesignificantly different across ICUs, with thesame clinical outcomesame clinical outcome

If we don’t know what we are doing,how shall we know how to improve it?

EURICUS studiesEURICUS studies has shown

Simple and limited interventions for improvingSimple and limited interventions for improving

• Collaborative Practice in the ICUCollaborative Practice in the ICU

• Budgeting and costing skills in the ICUBudgeting and costing skills in the ICU

• Patient OutcomePatient Outcome

• Perceived Collaborative Perceived Collaborative

PracticePractice

• Motivation to ManageMotivation to Manage

had a significantly positive effect uponhad a significantly positive effect upon

Less mortalityLess complications

EURICUS studiesEURICUS studies has shown

Burnout and Job-dissatisfactionBurnout and Job-dissatisfactionare more dependent of work uncertainty are more dependent of work uncertainty and less of workloadand less of workload

Organisational CommitmentOrganisational CommitmentResults-oriented CultureResults-oriented CultureDecision latitude of nursesDecision latitude of nursesPredictability of work-flowPredictability of work-flowOrganisational frameworkOrganisational frameworkimprove significantly ICU performanceimprove significantly ICU performance(patient- as well as human resource outcomes)

IMPLICATIONS

The non-clinical Organization and Managementof Hospital Departments

Focus on multidisciplinary care

Disciplines such as:Disciplines such as:Decision Theory Economics ManagementDecision Theory Economics ManagementOrganization Psychology Statistics and MethodologyOrganization Psychology Statistics and Methodology

Should take active responsibility in theShould take active responsibility in theorganization and management oforganization and management of

Health Care in the HospitalHealth Care in the Hospital

Focus on multidisciplinary careFocus on multidisciplinary care

Two recommended actions:Two recommended actions:

Implement the multidisciplinary Implement the multidisciplinary exposure of students in the exposure of students in the UniversityUniversity

Use the multidisciplinary expertise availableUse the multidisciplinary expertise availablein the Hospitalin the Hospital

In the Hospital of the future, non-clinical departmentsIn the Hospital of the future, non-clinical departments(e.g. finances, organization and management, etc.) will(e.g. finances, organization and management, etc.) willparallel clinical departments (cardiology, surgery, etc.)parallel clinical departments (cardiology, surgery, etc.)

The changes to be introduced in the organizationThe changes to be introduced in the organization and management of Health Care shall beand management of Health Care shall be commissioned to the macro level of policy makingcommissioned to the macro level of policy making in each countryin each country

The European Commission shall take a leading roleThe European Commission shall take a leading role

Need for centralInitiative & coordination

Need for centralInitiative & coordination

Only 30% of the nursing Only 30% of the nursing

timetime

is used in direct relation to is used in direct relation to

thethe

High Technology in the UnitHigh Technology in the Unit The urgent revision of the actual policies ofThe urgent revision of the actual policies ofNursing Careers is recommendedNursing Careers is recommended

THE THE EURICUSEURICUS PROJECTS PROJECTS

• EURICUS-I EURICUS-I (Survey)

The effect of OM

• EURICUS-II EURICUS-II (RCT)

The effect of standardising nursing tasksand of training collaborative practice

• EURICUS-III EURICUS-III (RCT)

The effect of use of guidelines

Medicine and NursingEconomicsOrg. Psychology Epidemiology

Medicine and NursingOccupational PsychologyTraining ConsultantsEpidemiology, Dec. Theory

Medicine and NursingOccupational PsychologyOrganisation & Manag.EconomicsCultureEpidemiology