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Administrative and Management Principles and Techniques A Review Course, Not a How-To Manual

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    1. Administrative and Management Principles and Techniques (A Review Course, Not a How-To Manual) Wendy Wright, MD Medical Director of the Neuroscience ICU Emory University Hospital Midtown Assistant Professor of Neurology, Neurosurgery and Pediatrics Emory University Hospital Atlanta, GA

    2. UCNS Exam Content Outline Organization and staffing of critical care units Collaborative practice principles, including multidisciplinary rounds and management Emergency medical systems in prehospital care Performance improvement, principles and practices Principles of triage and resource allocation, bed management Medical economics: health care reimbursement, budget development

    3. Introduction In the U.S. annually More than 4 million intensive care admissions1 At a cost of $200 billion2 1% of the GDP4 6000 ICUs house 55,000 patients per day2 20% mortality rate3

    4. Organization and Staffing No common staffing standards5,6 Nor could there be Structure of an ICU6 Includes physical aspects, biomedical equipment But also the how the multidisciplinary team is organized ICU leadership Quantity and quality of team How ICU is integrated into the rest of the hospital

    5. ICU Leadership Multi-professional committee Should meet regularly to identify and solve problems through quality assurance and continuous quality improvement activities7 Nursing director Integrates, facilitates and coordinates administrative and clinical practice for the nursing unit Serves as a professional role model, mentor, educator and clinical resource for nurses and other members of the health care team Medical Director

    6. Medical Director Give clinical, administrative, and educational direction to the ICU Assume responsibility for assuring the quality, safety, and appropriateness of care in the ICU Take ultimate authority for ICU admission, discharge, and triage Has the responsibility to ensure that the patients meet ICU admission and discharge criteria A clearly written procedure for conflict resolution as it relates to admission and discharge of patients should be in place Work collaboratively with the directors of other areas in the hospital so that patient care, triage, and patient flow are effective and efficient 7

    7. ICU Staffing Models Intensivist-led teams improve outcomes7,8 and lead to better use of resources9 Open vs. closed units11 High intensity vs. low intensity staffing4 Additional team members Critical care nurses, other physicians providing care, affiliate providers (nurse practitioners, physicians assistants), clinical pharmacists, etc.

    8. Collaborative Practice Principles Intensivists should strive to achieve an environment of collaborative co-management with primary medical services Communication should extend to any consulting service that may be involved with the patient as well Intensivists should collaborate with other hospital-based physicians such as hospitalists and emergency medicine physicians to improve care of critically ill patients as they move to and from the intensive care unit5

    9. Multidisciplinary Rounds Enhance coordination of care, increase the sense of collaborative co-management and increase communication amongst care providers5 Should include the treating intensivist, affiliate providers, critical care nurses and clinical care pharmacists; and for certain patients other personnel may be included Respiratory therapists, speech therapists, physical and occupational therapists, social workers and chaplains This model recognizes that the complexities of critical care and the importance of communication and cooperation to bring together all of the providers to deliver comprehensive care.8 May facilitate implementation of best clinical practices such as evidence-based treatment protocols, and are more likely to create and use checklists and other reminders.13

    10. Emergency Medical Systems in Prehospital Care Education of emergency medical services (EMS) personnel about the stabilization and transport of critically ill patients has proven invaluable, especially with regards to maintenance of airway and circulatory function Neurocritical care diseases such as status epilepticus, stroke and traumatic brain injury may have defined clinical care pathways for regional EMS workers to follow15

    11. Resuscitation Centers Efficient transport of the critically ill patient to an appropriate hospital is essential Resuscitation centers would be high volume hospitals that could dedicate resources to advance the care of the sickest patients, ideally for less money than lower-volume centers It is likely that several levels of resuscitation centers would be needed (similar to trauma center level designation) to increase the coverage of resuscitation centers throughout the population16

    12. Benefits Promotion of resuscitation-focused research Provision of evidence-based patient care Concentration of personnel and (expensive) resources, which requires a large commitment on the part of the hospital 16

    13. Barriers to Resuscitation Centers Achieving consensus on what criteria and which designating organization would be used Controversy surrounding the concept of bypassing one hospital to take a critically ill patient to a more distant specialty center First and foremost, it must be established that this is in the patients best interest The bypassed hospital may suffer a significant, negative impact on its reputation and financial well-being If hospitals are consistently bypassed, their staff may lose valuable skills, thereby making them even more ill-equipped to care for unstable patients who may arrive by private vehicle or may deteriorate in other areas of the hospital Not inconsequentially, long-standing physician-patient relationships may be disrupted. Regionalization of critical care services may lead to the unintended consequence of destabilizing the medical community in the event of a disaster 16

    14. Performance Improvement, Principles and Practices The Institute of Medicine defines quality health care as care that is safe, timely, effective, efficient, equitable, and patient-centered17 Improving care requires a system-wide commitment, with continual measurement and feedback in a culture that is entrenched in patient safety14 The three classic quality-of-care components are structure, process and outcome12

    15. Quality of Care Components Structure has to do with the staffing of the ICU, the type and amount of technology available, and how the ICU is integrated in to the rest of the hospital Process generally refers to what the care team does, or fails to do, to provide for patients and families Outcomes refer to the results achieved 12 Risk-adjusted mortality models are an important contribution but can not fully assess the quality of care given within an ICU There are a variety of outcome measures that reflect quality, including morbid events (nosocomial infections, adverse drug events, etc.), organ dysfunction, health related quality of life, and patient and family satisfaction.6

    16. Performance Review Guidelines published by the SCCM recommended a performance review of intensive care units at least annually Should include a review of the admission, discharge and triage policy Mechanism to review requested admissions that were denied should be in place to assess the appropriateness of the denials Any readmissions to the ICU for a similar problem should be evaluated for the appropriateness of the discharge policy7

    17. Quality Improvement Projects Prioritize and choose a project Ideally, this would be a feasible project that would have a high likelihood of being successfully completed Choosing a feasible, relevant project as an initial attempt will motivate team members to continue quality improvement projects in the future It is probably best to avoid overly-ambitious projects, and these projects can discourage team members and will consume resources It is important to foster the idea that quality improvement is an ongoing process, and not just related to one finite project.17 Write up a budget and timeline Tasks should be delineated and assigned to able and willing team members 6

    18. Quality Improvement Projects Environmental Scan will allow for the assessment of the current quality of care delivered 17 Creating a data collection system that is easy to use and accurately collects the desired quality indicator A good measure must be important, valid, reliable, responsive, interpretable, and feasible17 The next step in the quality improvement process is to describe the results, in terms of the primary outcomes May be mortality, length of stay, quality of life, outcomes after ICU discharge, cost, etc. Based on the findings, may need to introduce strategies to change behavior6

    19. Strategies to Changing Behavior Clinical protocols and care bundles Education Including managers, purchasers, payers and families Organizational guidelines Staffing, transfer, etc. Performance reporting Financial and behavioral incentives Regulation Legal requirements Reorganization of how care is delivered APs, medical outreach teams14

    20. Principles of Triage, Resource Allocation and Bed Management Triage is the process is prioritizing patients based on the severity of their condition ICU beds are an expensive resource, and ideally, should be reserved for patients with a reversible medical condition who have a reasonable prospect of recovery 7 Physician and nurse director should take primary responsibility for formalizing admission and discharge criteria, with input as needed from a multidisciplinary ICU committee Triage decisions may be made without patient or surrogate consent In principle, physicians should not feel compelled to provide care that is not medically indicated 7

    21. EMTALA If a person presents to a Medicare-eligible facility that provides emergency services and requests emergency care, they must receive a medical screening exam to identify whether an emergency medical condition exists IF the medical screening exam reveals an emergency medical condition, the treating hospital is obligated to stabilize the patient prior to discharge or transfer EMTALA rules also apply to any one on the hospital campus who requests or requires emergency services 250-yard-rule, 18

    22. EMTALA If an emergency medical condition is identified, the treating physician may feel that the patient requires a higher level of care and needs to be transferred Other potential reasons to transfer a patient out of an ED include Patient (or proxy) request If the on-call physician fails or refuses to appear within a reasonable period of time, such that the benefits of transfer outweigh the risks Transfer may also be undertaken the patient or health care proxyrequests transfer regardless of whether the emergency medical condition has been stabilized18

    23. EMTALA The receiving facility must accept the transfer AS LONG AS they have the capacity to accept the patient The implication is that the receiving hospital has some medical service, capability or provider type requires by the patient that the transferring facility does not have EMTALA applies to patients in the ED, NOT those admitted as inpatients The transferring hospital is obligated to provide all medical treatment within its capacity, as this will minimize the risk to the individual patients health The treating physician must send the pertinent medical record, including imaging studies and test results relating to the emergency medical condition to the receiving facility 18

    24. Resource Allocation Distributive or social justice is an ethical principle that states that resources should be allocated fairly throughout the population ICU can be a difficult place to make this happen A tremendous amount of resources are spent on patients who have little or no chance of meaningful recovery, a phenomenon that may be driven by expectations of the patients or surrogate decision makers or by fear of negative legal consequences U.S. reveals a climate of increasing demand for critical care, decreasing supply of valuable resources and retroactive denial of payment for services previously rendered 19

    25. Resource Allocation One study found that 40% of ICU resources were used to temporarily prolong the life of 9% of patients, and the mortality rate in these patients increased with the number of interventions20 In each ICU, the physician and nurse directors should determine the limits of care, telemetry, mechanical ventilation and types of intravenous medications7 and make sure that these limitations are clearly documented so that they can be uniformly applied to patients Use of clinically-based triggers (ex. APACHE score > 26) to obtain palliative care consultation has been one suggestion to try to divert valuable resources away from those unlikely to benefit from them2

    26. Cost Effectiveness in the ICU The biggest barrier to practicing cost effectiveness is the powerful human desire to save endangered human lives, known as the Rule of Rescue Saving costs in the ICU by reducing or eliminating life-saving treatments brings may therefore bring great conflict between comparative-effectiveness and the Rule of Rescue 21

    27. Bed Management Hospital-wide, 8% to 12% of beds are devoted to critical care in the United States, as opposed to 3% of hospital beds in non-U.S. countries There are countries with relatively low ICU bed density, such as Great Britain, Australia and Canada In these countries, when planning ICU needs, the number of beds is not increased unless a certain need is certified Appropriateness of ICU-use approaches can help identify low-risk patients and sometimes more flexible bed arrangements, such as intermediate care units, can be incorporated into the bed management strategies9

    28. Medical Economics: Health Care Reimbursement, Budget Development Current reimbursement is based on the Diagnosis-related group, or DRG, which is a system to classify hospital-based cases and will therefore dictate how much Medicare will reimburse21 Most private insurance companies have since adopted DRG-based payments Patients may have private insurance, that can be fee-for-service or function under a managed care model, or patients may be covered under one of the government payers (Medicare or Medicaid), which also have fee-for-service and managed care arms 21

    29. Budget Development Half of the a hospitals direct patient care budget2 and 15-20% of all hospital costs are attributable to critical care costs, but there are still more questions than answers as to how this money is best allocated9 There are costs that are fixed and those that are variable Fixed costs are those that are expected to be the same over time, and will not vary much based on patient load or severity, and include items such as capital expenditures, building maintenance, utilities, and employee salaries and benefits Variable costs include patient supplies, diagnostic and therapeutic supplies, medications and health care worker supplies

    30. Budget Development Developing a budget for the ICU will be very dependent on local factors and will be highly individualized depending on the number of staff and needs of the patients Staffing levels will likely constitute the majority of the budget (46- 56% on average) 9,22,23 European studies show an additional 22-27% expenditure on consumables which include drugs, fluids, nutrition, and blood 8.5-14.5% on clinical support services And 7.5% on non-clinical support services9

    31. Key Points Providing care to critically ill patients with intensivist-led multidisciplinary teams improves outcomes, resource utilization, and communication among health care provider ICU leadership ideally includes an ICU committee, a nursing director and a medical director (who is ultimately responsible for the care provided in the ICU, including admission and discharge criteria and the triage process) Staffing and budget needs are largely dependent on local factors Performance improvement is an ongoing process designed to continually reassess the needs of critically ill patients within a particular ICU in relation to structure, process, and outcomes

    32. Notable References (7) Egol A, Fromm R, Guntupalli KK, et al, on behalf of the Task Force of the American College of Critical Care Medicine and the Society of Critical Care Medicine. Guidelines for intensive care unit admission, discharge and triage. Crit Care Med 1999;27(3):633-638. (17) Curtis JR, Cook DJ, Wall RJ, et al. Intensive care unit quality improvement: A how-to guide for the interdisciplinary team. Criti Care Med 2006; 34(1):211-218. (19) Crippen D and Whetstine L. ICU resource allocation: life in the fast lane. Critical Care 1999; 3:R47-51.

    33. References 1. Halpern NA, Pastores SM, Greenstein RJ. Critical care medicine in the United States 1985-2000: an analysis of bed numbers, use and costs. Crit Care Med. 2004;32(6):1254-1259. 2. Bryan-Brown CW, Dracup K. Looking for a Few Just Men. American Journal of Critical Care 2005;14:178-180. 3. Angus DC, Barnato AE, Linde-zwirble WT, et al; Robert Wood Johnson Foundation ICU End-of-Life Peer Group. Use of intensive care at the end of life in the United States: an epidemiologic study. Crit Care Med 2004;32(3):638-643. 4. Pronovost PJ, Angus DC, Dorman T, et al. Physician staffing patterns and clinical outcomes in critically ill patients. JAMA 2002; 288:2151-2162. 5. Kelley MA, Angus M, Chalfin B, et al. The critical care crisis in the United States: a report from the profession. Chest 1004; 125: 1514-1517. 6. Barbieri C, Carson C, and Amaral AC. Year in review 2007: Critical Care- Intensive Care Unit Management. Crit Care Med 2009; 12:229-234. 8. Kim MM, Baranato AE, Angus EC, et al. The effect of multidisciplinary care teams on intensive care unit mortality. Arch Intern Med 2010; 170 (4):369-376. 9. Wild C, Narath M. Evaluating and planning ICUs: methods and approaches to differentiate between need and demand. Health Policy 2005; 71:289-301. 10. Pronovost PJ, Angus DC, Dorman T, et al. Physician staffing patterns and clinical outcomes in critically ill patients: as systematic review. JAMA 2002:288(17):2151-2162. 11. Milstein A, Galvin RS, Delblanco SF, et al. Improving the safety of health care: the Leapfrog initiative. Eff Clin Pract 2000;3(6):313-316. 12. Morrison AL, Beckmann U, Durie M, et al. The effects of nursing staff inexperience (NSI) on the occurrence of adverse patient experiences in ICUs. Aust Crit Care 2001;14:116-121. 13. Murphy DJ, Fan E, and Needham DM. ICU staffing and patient outcomes: more work remains. Crit Care Med 2009;13(1):101-102. 14. Angus DC and Black N. Improving care of the critically ill: institutional and healthcare system approaches. Lancet 2004;363 (9417): 1314-1320. 15. Minardi J and Crocco TJ. Management of traumatic brain injury: first link in chain of survival. Mount Sinai Journal of Medicine 2009; 76: 138-144. 16. Mechem CC, Goodleo JM, Richmond NL, et al. Resuscitation center designation: Recommendations for Emergency Medical Services practices. Prehospital Emergency Care 2010; 14:51-61. 18. Schecter JC. COBRA Laws and EMTALA. 2009. 20. Sheffler RM. Severity of illness and the relationship between intensive care and survival. Am J Pub Healh 1981;725:449. 21. Luce JM and Rubenfeld GD. Can health care costs be reduced by limiting intensive care at the end of life? Am J Respir Crit Care Med 2002; 165: 750-754. 22. Edbrooke D, Ridley A, et al. Variations in expenditure between adult general intensive care units in the UK. Anaesthesia 2001;56:20816. 23. EURICUS III. The implementation of guidelines for budget control and cost calculation, and their effect on the quality of management of intensive care units in the countries of the European Union. Groningen, Foundation for Research on Intensive Care in Europe (FRICE). 2001.