The continuing imperative to measure workload in ICU: impact on patient safety and staff well-being

Intensive care unit caseload and workload and their association with outcomes in critically unwell patients: a large registry-based cohort analysis

BACKGROUND

Too high or too low patient volumes and work amounts may overwhelm health care professionals and obstruct processes or lead to inadequate personnel routine and process flow. We sought to evaluate, whether an association between current caseload, current workload, and outcomes exists in intensive care units (ICU).

METHODS

Retrospective cohort analysis of data from an Austrian ICU registry. Data on patients aged ≥ 18 years admitted to 144 Austrian ICUs between 2013 and 2022 were included. A Cox proportional hazards model with ICU mortality as the outcome of interest adjusted with patients' respective SAPS 3, current ICU caseload (measured by ICU occupancy rates), and current ICU workload (measured by median TISS-28 per ICU) as time-dependent covariables was constructed. Subgroup analyses were performed for types of ICUs, hospital care level, and pre-COVID or intra-COVID period.

RESULTS

415 584 patient admissions to 144 ICUs were analysed. Compared to ICU caseloads of 76 to 100%, there was no significant relationship between overuse of ICU capacity and risk of death [HR (95% CI) 1.06 (0.99-1.15), p = 0.110 for > 100%], but for lower utilisation [1.09 (1.02-1.16), p = 0.008 for ≤ 50% and 1.10 (1.05-1.15), p < 0.0001 for 51-75%]. Exceptions were significant associations for caseloads > 100% between 2020 and 2022 [1.18 (1.06-1.30), p = 0.001], i.e., the intra-COVID period. Compared to the reference category of median TISS-28 21-30, lower [0.88 (0.78-0.99), p = 0.049 for ≤ 20], but not higher workloads were significantly associated with risk of death. High workload may be associated with higher mortality in local hospitals [1.09 (1.01-1.19), p = 0.035 for 31-40, 1.28 (1.02-1.60), p = 0.033 for > 40].

CONCLUSIONS

In a system with comparably high intensive care resources and mandatory staffing levels, patients' survival chances are generally not affected by high intensive care unit caseload and workload. However, extraordinary circumstances, such as the COVID-19 pandemic, may lead to higher risk of death, if planned capacities are exceeded. High workload in ICUs in smaller hospitals with lower staffing levels may be associated with increased risk of death.

How COVID-19 has affected staffing models in intensive care: A qualitative study examining alternative staffing models (SEISMIC)

AIMS

To understand how COVID-19 affected nurse staffing in intensive care units (ICUs) in England, and to identify factors that influenced, and were influenced by, pandemic staffing models.

DESIGN

Exploratory qualitative study.

METHODS

Semi-structured, online interviews conducted July-September 2020 with regional critical care leaders including policy leads (n = 4) and directors/lead nurses (n = 10) across critical care networks in England.

FINDINGS

The six themes emerging from the framework analysis illustrate how the pre-pandemic ICU culture influenced ICU staffing models during the pandemic. Changes in staffing impacted on the workforce and the care delivered, whilst it was necessary to learn from, and adjust to, a rapidly changing situation. Variation across and between networks necessitated variation in responses. The overwhelming outcome was that the pandemic has challenged the central tenets of ICU nurse staffing.

CONCLUSIONS

Pandemic nurse staffing models resulted in changes to ICU skill-mix and staffing numbers. Factors such as the impact of nurse staffing on care practices and on the workforce need to be taken into account when developing and testing future nurse staffing models for ICU. The extent to which ICUs will return to former staffing models is not yet known but there seems to be an appetite for change.

IMPACT

In common with many countries, nurse staffing in English ICUs was adapted to address surge requirements during the COVID-19 pandemic. Findings highlight the challenge COVID-19 presented to pre-pandemic ICU nurse staffing guidelines, the impact on patient and staff well-being and the potential legacy for future staffing models. Study findings have implications for ICU nurse managers, researchers and policy makers: nurse staffing models need to be adaptable to the local context of care and future research should investigate the impact of different models on patients, staff and health service outcomes.

Intensive care digital health response to emerging infectious disease outbreaks such as COVID-19

The COVID-19 pandemic has required intensive care units to rapidly adjust and adapt their existing practices. Although there has a focus on expanding critical care infrastructure, equipment and workforce, plans have not emphasised the need to increase digital capabilities. The objective of this report was to recognise key areas of digital health related to the COVID-19 response. We identified and explored six focus areas relevant to intensive care, including using digital solutions to increase critical care capacity, developing surge capacity within an electronic health record, maintenance and downtime planning, training considerations and the role of data analytics. This article forms the basis of a framework for the intensive care digital health response to COVID-19 and other emerging infectious disease outbreaks.

Nursing Turbulence in Critical Care: Relationships With Nursing Workload and Patient Safety

BACKGROUND

Increased nursing workload can be associated with decreased patient safety and quality of care. The associations between nursing workload, quality of care, and patient safety are not well understood.

OBJECTIVES

The concept of workload and its associated measures do not capture all nursing work activities, and tools used to assess healthy work environments do not identify these activities. The variable turbulence was created to capture nursing activities not represented by workload. The purpose of this research was to specify a definition and preliminary measure for turbulence.

METHODS

A 2-phase exploratory sequential mixed-methods design was used to translate the proposed construct of turbulence into an operational definition and begin preliminary testing of a turbulence scale.

RESULTS

A member survey of the American Association of Critical-Care Nurses resulted in the identification of 12 turbulence types. Turbulence was defined, and reliability of the turbulence scale was acceptable (α = .75). Turbulence was most strongly correlated with patient safety risk (r = 0.41, n = 293, P < .001). Workload had the weakest association with patient safety risk (r = 0.16, n = 294, P = .005).

CONCLUSIONS

Acknowledging the concepts of turbulence and workload separately best describes the full range of nursing demands. Improved measurement of nursing work is important to advance the science. A clearer understanding of nurses' work will enhance our ability to target resources and improve patients' outcomes.

Use of the Omaha System to identify musculoskeletal problems in intensive care unit nurses: a case study

BACKGROUND:

there is a need for a standard terminology to identify and manage occupational risks in intensive care unit (ICU) settings.

AIM:

this study was conducted to investigate the occupational musculoskeletal symptom-related problems of one ICU nurse using the Omaha system.

METHOD:

a case study method was employed. An Evaluation of Knowledge form and Rapid Upper Limb Assessment tools were used to identify musculoskeletal symptoms and ergonomic risks. Three components of the Omaha System were used: Problem Classification Scheme, Intervention Scheme and Problem Rating Scale for Outcomes.

RESULTS:

eight signs/symptoms related to four problems were identified from three domains: environmental (neighbourhood/workplace safety), physiological (pain and neuro-musculoskeletal function), and health-related behaviours (physical activity and healthcare supervision). Interventions were mapped to Omaha System terms, and nursing outcomes were evaluated.

CONCLUSION:

this study presented an example of using the Omaha System in occupational health nursing practice. The Omaha System can be used effectively to identify musculoskeletal problems and related factors of ICU nurses in a standardised and computerised concept. Use of this system could aid prevention of occupational musculoskeletal problems in ICU nurses.

Caregivers' perceptions towards communication with mechanically ventilated patients: The results of a multicenter survey

PURPOSE

The purpose of this study was to investigate ICU health care providers' perception towards communication and associated problems with mechanically ventilated (MV) patients. The primary aim was to quantify the extent of the problem and to determine its effect on patient care and job satisfaction.

METHODS

A multicenter survey study was conducted among nurses, residents and intensivists of 15 ICUs in the Netherlands using an online questionnaire.

RESULTS

Out of 1740 caregivers, 457 responses were received. Communication difficulties were experienced in half of the interactions with MV patients. Over 75% of participants indicated that patient care was negatively affected. Job satisfaction was negatively affected in 43% of the participants, primarily with feelings of unfulfillment (76%) and frustration (72%). Patient factors considered relevant to communication difficulties were delirium, disease severity and anxiety, among others. To facilitate communication, the use of basic gestures remained the most preferred method.

CONCLUSIONS

In half of the interactions with MV patients, health care professionals experience significant communication difficulties. The respondents indicated that these difficulties frequently lead to negative effects on patient care and job satisfaction. These results emphasize the need for improvements such as the development of communication protocols, skills training and continued research into new communication methods.

The Impact of Telemedicine on Teamwork and Workload in Pediatric Resuscitation: A Simulation-Based, Randomized Controlled Study

BACKGROUND

Telemedicine provides access to specialty care to critically ill patients from a geographic distance. The effects of using telemedicine on (1) teamwork and communication (TC), (2) task workload during resuscitation, and (3) the processes of critical care have not been well described.

OBJECTIVES

To evaluate the impact of telemedicine on (1) TC, (2) task workload during a resuscitation, and (3) the processes of critical care during a simulated pediatric resuscitation.

METHODS

Prospective single-center randomized trial. Teams of two physicians (senior and junior resident) and two standardized confederate nurses were randomized to either telemedicine (telepresent senior physician team leader) or usual care (both physicians in the room) during a simulated infant resuscitation. Simulations were video recorded and assessed for teamwork, workload, and processes of care using the Simulated Team Assessment Tool (STAT), the NASA Task Load Index (NASA-TLX) tool, and time between onset of ventricular fibrillation and defibrillation, respectively.

RESULTS

Twenty teams participated. There was no difference in teamwork between the groups (mean STAT score 72% vs. 69%; p = 0.383); however, there was a significantly greater workload in the telemedicine group (mean TLX score 56% vs. 48%, p = 0.020). Using linear regression, no difference was found in time-to-defibrillation between groups (p = 0.671), but higher teamwork scores predicted faster time to defibrillation (p = 0.020).

CONCLUSIONS

In this simulation-based study, a telepresent team leader was associated with increased team workload compared to usual care. However, no differences were noted in teamwork and processes of care metrics.

Association between patient classification systems and nurse staffing costs in intensive care units: An exploratory study

OBJECTIVES

Nurse staffing costs represent approximately 60% of total intensive care unit costs. In order to analyse resource allocation in intensive care, we examined the association between nurse staffing costs and two patient classification systems: the nursing activities score (NAS) and nine equivalents of nursing manpower use score (NEMS).

RESEARCH METHODOLOGY/DESIGN

A retrospective descriptive correlational analysis of nurse staffing costs and data of 6390 patients extracted from a data warehouse.

SETTING

Three intensive care units in a university hospital and one in a regional hospital in Norway.

MAIN OUTCOME MEASURES

Nurse staffing costs, NAS and NEMS.

RESULTS

For merged data from all units, the NAS was more strongly correlated with monthly nurse staffing costs than was the NEMS. On separate analyses of each ICU, correlations were present for the NAS on basic costs and external overtime costs but were not significant. The annual mean nurse staffing cost for 1% of NAS was 20.9-23.1 euros in the units, which was comparable to 53.3-81.5 euros for 1 NEMS point.

CONCLUSION

A significant association was found between monthly costs, NAS, and NEMS. Cost of care should be based on individual patients' nursing care needs. The NAS makes nurses' workload visible and may be a helpful classification system in future planning and budgeting of intensive care resources.

Assessment of Weight Bias Among Pediatric Nurses and Clinical Support Staff Toward Obese Patients and Their Caregivers

The increasing burden of obesity is prevalent in the pediatric populations. Pediatric nurses are spending increasing amounts of time and effort caring for obese patients however no prior studies have explored how nurses perceive obese patients. The purpose of this study is to identify weight bias in pediatric nurses (RNs) and clinical support staff (CSS) working in a pediatric hospital setting. A convenience sample of RNs and CSS from an urban, pediatric hospital were surveyed using the Nurses' Attitudes toward Obesity and Obese Patients Scale (NATOOPS), which consists of 6 patient-care factors with an additional factor added to assess bias towards the patient's caregiver. Mean factor scores ≥50 indicated bias. Data were summarized using descriptive statistics and means were compared using independent t tests. Multivariate logistic regression models were used to determine the association between putative risk factors and weight bias. RNs and CSS (N=308) demonstrated weight bias toward obese patient characteristics (mean=61.9) and perceived controllability of obesity (mean=65.8). CSS felt negatively about their supportive roles in caring for obese patients (mean=52.5). Respondent weight status and professional title resulted in variability of biased attitudes. Race, employment status, number of obese patients cared for daily, and department were predictive of biased attitudes. Weight biased attitudes toward obese pediatric patients and their caregivers were found among RNs and CSS. Future qualitative research will assist in the understanding the factors that cause nurse weight bias.

Approaches to decreasing medication and other care errors in the ICU

PURPOSE OF REVIEW

The very complex process of intensive care is accompanied by a not unexpected accumulation of risk for error and adverse events. The present review addresses strategies to decrease care errors in several domains of daily intensive care practice.

RECENT FINDINGS

Strategies to decrease care errors now focus on a systematic approach by identifying latent system failures and change the design of the care process in such a way that inevitable human errors are prevented or their consequences are mitigated. Recent examples refer to the standardization of processes, adaptation to cognitive limitations of human beings, optimization of working conditions, and the increasing use of supporting information technologies. The development of a safety climate constitutes a key element and apparently contributes to reduction of medical errors in ICUs.

SUMMARY

The present review discusses recent approaches aimed to decrease care errors in ICUs. A growing body of evidence demonstrates that a system based approach with the change of process characteristics and the development of a safety climate is most essential in the effort to increase patient safety.

The culture of patient safety in an Iranian intensive care unit

AIM

To explore nurses' and physicians' attitudes and perceptions relevant to safety culture and to elicit strategies to promote safety culture in an intensive care unit.

BACKGROUND

A strong safety culture is essential to ensure patient safety in the intensive care unit.

METHOD

This case study adopted a mixed method design. The Safety Attitude Questionnaire (SAQ-ICU version), assessing the safety climate through six domains, was completed by nurses and physicians (n = 42) in an academic intensive care unit. Twenty semi-structured interviews and document analyses were conducted as well. Interviews were analysed using a framework analysis method.

RESULT

Mean scores across the six domains ranged from 52.3 to 72.4 on a 100-point scale. Further analysis indicated that there were statistically significant differences between physicians' and nurses' attitudes toward teamwork (mean scores: 64.5/100 vs. 52.6/100, d = 1.15, t = 3.69, P < 0.001) and job satisfaction (mean scores: 78.2/100 vs. 57.7/100, d = 1.5, t = 4.8, P < 0.001). Interviews revealed several safety challenges including underreporting, failure to learn from errors, lack of speaking up, low job satisfaction among nurses and ineffective nurse-physician communication.

CONCLUSION

The results indicate that all the domains need improvements. However, further attention should be devoted to error reporting and analysis, communication and teamwork among professional groups, and nurses' job satisfaction.

IMPLICATIONS FOR NURSING MANAGEMENT

Nurse managers can contribute to promoting a safety culture by encouraging staff to report errors, fostering learning from errors and addressing inter-professional communication problems.