Nurse staffing and patient outcomes in critical care: A concise review

Priority analysis of educational needs for new nurses in the intensive care unit: A cross-sectional study

BACKGROUND

New intensive care unit (ICU) nurses often experience stress because of concerns about potentially harming their patients in a work environment that demands the rapid development of several skills in a limited training period.

AIM

This study aimed to investigate the prioritisation of educational needs within adult ICUs, focusing on how new nurses evaluate their current knowledge and perceive the most critical competencies.

STUDY DESIGN

A cross-sectional study was conducted among a convenience sample of 102 new ICU nurses in general and tertiary hospitals in South Korea. Educational needs were assessed using a structured questionnaire for new ICU nurses. This study investigated educational needs using paired t-tests, Borich's assessment model and the Locus for Focus model.

RESULTS

Only 48% of participants were satisfied with their education. The highest-rated educational content included preparing to use a defibrillator (95% CI = 2.44-3.28, p < .001), administering emergency drugs for cardiopulmonary resuscitation (CPR) (95% CI = 2.09-2.91, p < .001), starting and maintaining continuous renal replacement therapy (95% CI = 1.50-2.42, p < .001), applying and maintaining a ventilator (95% CI = 1.42-2.08, p < .001), preparing for intubation (95% CI = 1.23-1.97, p < .001), reporting to the emergency team, preparing equipment for CPR (95% CI = 1.12-1.94, p < .001) and drug calculation (95% CI = 0.87-1.53, p < .001).

CONCLUSIONS

These findings indicate that educational programmes for new ICU nurses should be developed considering the aforementioned priorities. Furthermore, nurse educators should adopt a practical and active instructional method to repeatedly clarify content, prioritising the improvement of knowledge and performance of new ICU nurses.

RELEVANCE TO CLINICAL PRACTICE

This study guides clinical educators and managers in focusing on areas where new ICU nurses need additional training. Effective nurse residency programmes tailored to the specific needs of new ICU nurses can enhance their confidence and ability to handle ICU nursing challenges.

Factors Affecting the Field Adaptation of Early-Stage Nurses in South Korea

Supporting early-stage nurses to adapt to the field and become proficient in nursing is important to improve the quality of patient care. This study aimed to determine the effects of the nursing work environment, nursing practice readiness, and optimism on the field adaptation of early-stage nurses. A descriptive survey was conducted among 209 early-stage nurses with ≤3 years of work experience at hospitals. The collected data were analyzed using descriptive statistics, the t-test, ANOVA, Pearson's correlation coefficients, and regression analysis with the SPSS Program. The participating nurses' mean field adaptation score was 2.90 ± 0.40 (total score = 5) and a significant positive correlation was found between nursing work environment (r = 0.61, p < 0.001), nursing practice readiness (r = 0.41, p < 0.001), and optimism (r = 0.26, p < 0.001). The regression analysis revealed that the nursing work environment (β = 0.38, p < 0.001), job satisfaction (β = 0.33, p < 0.001), nursing practice readiness (β = 0.24, p < 0.001), and turnover intention (β = 0.17, p = 0.001) significantly affect the field adaptation of early stage nurses; the explanatory power was 56.1% (F = 27.55, p < 0.001). The results suggest that to facilitate the field adaptation of early-stage nurses, the nursing work environment, job satisfaction, and nursing practice readiness should be improved. Improvement in the nursing work environment and the development of additional training for field adaptation would enhance the ability of early-stage nurses to adapt to the field and, consequently, improve the quality of nursing care.

Analytical Review of Unplanned Extubation in Intensive Care Units and Recommendation on Multidisciplinary Preventive Approaches

Unplanned extubations (UE) frequently occur in critical care units. These events are precipitated by many risk factors and are associated with adverse outcomes for patients. We reviewed the current literature to examine factors related to UE and presented the analysis of 41 articles critical to the topic. Our review has identified specific risk factors that we discuss in this review, such as sedation strategies, physical restraints, endotracheal tube position, and specific nursing care aspects associated with an increased incidence of UE. We recommend interventions to reduce the risk of UE. However, we recommend that bundled rather than a single intervention is likely to yield higher success, given the heterogeneity of factors contributing to increasing the risk of UE.

Association between nurse staffing level in intensive care settings and hospital-acquired pneumonia among surgery patients: result from the Korea National Health Insurance cohort

This study examined the association between the number of nursing staff in intensive care units (ICUs) and hospital-acquired pneumonia (HAP) among surgical patients in South Korea. Data were obtained between 2008 and 2019 from the Korean National Health Insurance Service Cohort Database; 37,706 surgical patients who received critical care services were included in the analysis. Patients with a history of pneumonia 1 year prior to surgery or those who had undergone lung-related surgery were excluded. The ICU nursing management fee is an admission fee that varies based on the grading determined by nurse-to-bed ratio. Using this grading system, we classified four groups from the highest to the lowest level based on the proportion of beds to nurses (high, high-mid, mid-low, and low group). HAP was defined by the International Classification of Disease, 10th revision (ICD-10) code. Multilevel logistic regression was used to investigate the relationship between the level of ICU nurse staffing and pneumonia, controlling for variables at the individual and hospital levels. Lower levels of nurse staffing were associated with a greater incidence of HAP than higher levels of nurse staffing (mid-high, OR: 1.33, 95% CI: 1.12-1.57; mid-low, OR: 1.61, 95% CI: 1.27-2.04; low, OR: 2.13, 95% CI: 1.67-2.71). The intraclass correlation coefficient value was 0.177, and 17.7% of the variability in HAP was accounted for by the hospital. Higher ICU nursing management fee grades (grade 5 and above) in general and hospital settings were significantly associated with an increased risk of HAP compared to grade 1 admissions. Similarly, in tertiary hospitals, grade 2 and higher ICU nursing management fees were significantly associated with an increased risk of HAP compared to grade 1 admissions. Especially, a lower level of nurse staffing was associated with bacterial pneumonia but not pneumonia due to aspiration. In conclusion, this study found an association between the level of ICU nurse staffing and HAP among surgical patients. A lower level of nurse staffing in the ICU was associated with increased rates of HAP among surgical patients. This indicates that having fewer beds assigned to nurses in the ICU setting is a significant factor in preventing HAP, regardless of the size of the hospital.

Intensive care unit mortality and cost-effectiveness associated with intensivist staffing: a Japanese nationwide observational study

BACKGROUND

Japan has four types of intensive care units (ICUs) that are divided into two categories according to the management fee charged per day: ICU management fees 1 and 2 (ICU1/2) (equivalent to high-intensity staffing) and 3 and 4 (ICU3/4) (equivalent to low-intensity staffing). Although ICU1/2 charges a higher rate than ICU3/4, no cost-effectiveness analysis has been performed for ICU1/2. This study evaluated the clinical outcomes and cost-effectiveness of ICU1/2 compared with those of ICU3/4.

METHODS

This retrospective observational study used a nationwide Japanese administrative database to identify patients admitted to ICUs between April 2020 and March 2021 and divided them into the ICU1/2 and ICU3/4 groups. The ICU mortality rates and in-hospital mortality rates were determined, and the incremental cost-effectiveness ratio (ICER) (Japanese Yen (JPY)/QALY), defined as the difference between quality-adjusted life year (QALY) and medical costs, was compared between ICU1/2 and ICU3/4. Data analysis was performed using the Chi-squared test; an ICER of < 5 million JPY/QALY was considered cost-effective.

RESULTS

The ICU1/2 group (n = 71,412; 60.7%) had lower ICU mortality rates (ICU 1/2: 2.6% vs. ICU 3/4: 4.3%, p < 0.001) and lower in-hospital mortality rates (ICU 1/2: 6.1% vs. ICU 3/4: 8.9%, p < 0.001) than the ICU3/4 group (n = 46,330; 39.3%). The average cost per patient of ICU1/2 and ICU3/4 was 2,249,270 ± 1,955,953 JPY and 1,682,546 ± 1,588,928 JPY, respectively, with a difference of 566,724. The ICER was 718,659 JPY/QALY, which was below the cost-effectiveness threshold.

CONCLUSIONS

ICU1/2 is associated with lower ICU patient mortality than ICU3/4. Treatments under ICU1/2 are more cost-effective than those under ICU3/4, with an ICER of < 5 million JPY/QALY.

Nursing workload and patient-focused outcomes in intensive care: A systematic review

The aim of this systematic review was to examine the association of nursing workload on patient outcomes in intensive care units. The primary outcome measure was patient mortality, with adverse events (AE), the secondary outcome measures. Electronic search of databases including MEDLINE, CINAHL, Cochrane, EMCARE, Scopus, and Web of Science were performed. Studies were excluded if they were in non-ICU settings, pediatric, neonatal populations, or if the abstract/full text was unavailable. Risk of bias was assessed by the ROBINS-I tool. After screening 4129 articles, 32 studies were identified as meeting inclusion criteria. The majority of included studies were assessed as having a moderate risk of bias. The nursing activities score (NAS) was the most frequently used tool to assess nursing workload. Our systematic review identified that higher nursing workload was associated with patient-focused outcomes, including increased mortality and AE in the intensive care setting. The varied approaches of measuring and reporting nursing workload make it difficult to translate the findings of the impact of nursing workload on patient outcomes in intensive care settings.

A Nursing Care Model for Surge Capacity Management in Intensive Care Units During the COVID-19 Pandemic: Experience From Qatif Central Hospital, Saudi Arabia

Introduction The COVID-19 pandemic resulted in a surge of critically ill patients requiring intensive care. This posed challenges for healthcare systems in managing increased ICU bed demands with limited resources. Methods A retrospective qualitative review of institutional documents and plans was conducted. Key strategies related to ICU bed expansion, nursing staff classification and training, clinical supervision, and performance evaluation were analyzed. Results Qatif Central Hospital increased ICU beds from 20 to 50 by converting other clinical areas. Nursing staff were categorized based on critical care experience, and additional training was provided to non-ICU nurses. A preceptor-led nursing care model with staff responsibilities was implemented. Periodic evaluations ensured continued competence.  Conclusion The nursing care model at Qatif Central Hospital effectively facilitated ICU surge capacity while maintaining care quality. The model offers a viable framework for other healthcare institutions facing similar challenges. However, the study is limited by its retrospective design and focus on a single institution.

The Effect of Burnout and Moral Sensitivity Levels of Surgical Unit Nurses on Job Satisfaction

PURPOSE

This study was carried out to determine the effect of burnout and moral sensitivity levels of surgical unit nurses on their job satisfaction.

DESIGN

A descriptive and correlational design study.

METHODS

The population consisted of 268 nurses working in health institutions in the Eastern Black Sea Region of Turkey. The data were collected online between 1 and 30 April, 2022 using a sociodemographic data form, the Maslach Burnout Inventory, the Minnesota Job Satisfaction Scale, and the Moral Sensitivity Scale. Pearson correlation analysis and logistic regression analysis were used to evaluate the data.

FINDINGS

The nurses' moral sensitivity scale mean score was 105.2 ± 18.8, and the Minnesota job satisfaction scale mean score was 3.3 ± 0.7. The participants' mean emotional exhaustion score was 25.4 ± 7.3, the depersonalization score average was 15.7 ± 4.6, and the personal accomplishment mean score was 20.5 ± 6.7. The factors affecting the job satisfaction of nurses were found to be moral sensitivity, personal accomplishment, and satisfaction with the unit they worked.

CONCLUSIONS

Nurses had high levels of burnout due to emotional exhaustion, one of the subdimensions of burnout, and moderate levels of burnout due to depersonalization and personal accomplishment. The moral sensitivity and job satisfaction of nurses are moderate. As the nurses' accomplishment and ethical sensitivity levels increased and their emotional exhaustion levels decreased, their job satisfaction levels increased.

The relationship between nursing skill mix and severity of illness of patients admitted in Australian and New Zealand intensive care units

BACKGROUND

Critically ill patients in the intensive care environment require an appropriate nursing workforce to improve quality of care and patient outcomes. However, limited information exists as to the relationship between severity of illness and nursing skill mix in the intensive care.

OBJECTIVE

The aim of this study was to describe the variation in nursing skill mix across different hospital types and to determine if this was associated with severity of illness of critically ill patients admitted to adult intensive care units (ICUs) in Australia and New Zealand.

DESIGN & SETTING

A retrospective cohort study using the Australia and New Zealand Intensive Care Society Adult Patient Database (to provide information on patient demographics, severity of illness, and outcome) and the Critical Care Resources Registry (to provide information on annual nursing staffing levels and hospital type) from July 2014 to June 2020. Four hospital types (metropolitan, private, rural/regional, and tertiary) and three patient groups (elective surgical, emergency surgical, and medical) were examined.

MAIN OUTCOME MEASURE

The main outcome measure was the proportion of critical care specialist registered nurses (RNs) expressed as a percentage of the full-time equivalent (FTE) of total RNs working within each ICU each year, as reported annually to the Critical Care Resources Registry.

RESULTS

Data were examined for 184 ICUs in Australia and New Zealand. During the 6-year study period, 770 747 patients were admitted to these ICUs. Across Australia and New Zealand, the median percentage of registered nursing FTE with a critical care qualification for each ICU (n = 184) was 59.1% (interquartile range [IQR] = 48.9-71.6). The percentage FTE of critical care specialist RNs was highest in private [63.7% (IQR = 52.6-78.2)] and tertiary ICUs [58.1% (IQR = 51.2-70.2)], followed by metropolitan ICUs [56.0% (IQR = 44.5-68.9)] with the lowest in rural/regional hospitals [55.9% (IQR = 44.9-70.0)]. In ICUs with higher percentage FTE of critical care specialist RNs, patients had higher severity of illness, most notably in tertiary and private ICUs. This relationship was persistent across all hospital types when examining subgroups of emergency surgical and medical patients and in multivariable analysis after adjusting for the type of hospital and relative percentage of each diagnostic group.

CONCLUSIONS

In Australian and New Zealand ICUs, the highest acuity patients are cared for by nursing teams with the highest percentage FTE of critical care specialist RNs. The Australian and New Zealand healthcare system has a critical care nursing workforce which scales to meet the acuity of ICU patients across Australia and New Zealand.

The Impact of Nursing Skill-mix on Adverse Events in Intensive Care: A Single Centre Cohort Study

BACKGROUND

The highly complex and technological environment of critical care manages the most critically unwell patients in the hospital system, as such there is a need for a highly trained nursing workforce. Intensive care is considered a high-risk area for errors and adverse events (AE) due to the severity of illness and number of procedures performed.

OBJECTIVE

To investigate if the percentage of Critical Care Registered Nurses (CCRN) within an Intensive Care Unit (ICU) is associated with an increased risk of patients experiencing an AE.

DESIGN & SETTING

We conducted a retrospective cohort study of patients admitted between January 2016 and December 2020 to a tertiary ICU in Australia. Descriptive statistics and multivariable logistic regression were used to investigate the relationship between the proportion of CCRNs each month and the occurrence of an AE defined as any one of a medication error, fall, pressure injury or unplanned removal of a central venous catheter or endotracheal tube per patient.

RESULTS

A total of 13,560 patients were included in the study, with 854 (6.3%) experiencing one AE. Patients with an AE were associated with higher illness severity and frailty scores. They were more commonly admitted after medical emergency team response calls and were less commonly elective ICU admissions. Those with an AE had longer ICU and in-hospital length of stay, and higher ICU and in-hospital mortality, on average. After adjusting for ICU LOS and acute severity of illness, being admitted during a month of higher critical care nursing skill-mix was associated with a statistically significant lower odds of having a subsequent AE (OR 0.966 [95% CI: 0.944-0.988], p 0.003).

CONCLUSION

An increasing percentage of CCRNs is independently associated with a lower risk-adjusted likelihood of an AE. Increasing the skill-mix of the ICU nursing staff may reduce the occurrence of AEs and lead to improved patient outcomes.

The Relationship of Nurse and Physician Staffing in Intensive Care Units with Patient Outcomes in Postoperative Patients on Ventilators: An Analysis Using Korean National Health Insurance Data

This study examined the associations of nurse and physician staffing in intensive care units (ICUs) with hospital-acquired pneumonia (HAP) incidence and in-hospital mortality in postoperative patients on ventilators. National Health Insurance claims data and death statistics were used to investigate the nurse staffing level and the presence or absence of a dedicated resident and specialist in each ICU. The participants were patients aged 20-85 who underwent any of 13 surgical procedures and were placed on a ventilator in the ICU after the procedure. Of 11,693 patients, 307 (2.6%) experienced HAP and 1280 (10.9%) died during hospitalization. Compared to hospitals with lower nurse-to-patient ratios, patients in hospitals with higher ratios had statistically significantly higher risks of HAP and in-hospital mortality. The presence of a dedicated resident in the ICU did not statistically significantly affect HAP incidence or in-hospital mortality. The presence of an ICU specialist was statistically significantly associated with in-hospital mortality but not HAP incidence. Our findings suggest that a higher level of nursing staff in the ICU is inversely associated with HAP incidence. The legal standards for nurse staffing in the ICU should be strengthened in order to improve the quality of care and patient safety.

Mortality among acute myocardial infarction patients admitted to hospitals on weekends as compared with weekdays in Taiwan

Weekend effect has been considered to be associated with poorer quality of care and patient's survival. For acute myocardial infarction (AMI) patients, the question of whether patients admitted during off-hours have worse outcomes as compared with patients admitted during on-hours is still inconclusive. We conducted this study to explore the weekend effect in AMI patients, using a nationwide insurance database in Taiwan. Using Taiwan National Health Insurance (NHI) claims database, we designed a retrospective cohort study, and extracted 184,769 incident cases of AMI through the NHI claims database between January 2006 and December 2014. We divided the patients into weekend admission group and weekday admission group. Patients were stratified as ST elevation/non-ST elevation AMI and receiving/not receiving percutaneous coronary intervention (PCI). We used a logistic regression model to examine the relative risk of in-hospital mortality and 1-year mortality which were obtained from the Taiwan National Death Registry between study groups. We found no difference between weekend group and weekday group for risk of in-hospital mortality (15.8% vs 16.2%, standardized difference 0.0118) and risk of 1-year mortality (30.2% vs 30.9%, standardized difference 0.0164). There was no statistically significant difference among all the comparisons through the multivariate logistic regression analysis adjusting for all the covariates and stratifying by the subtypes of AMI and whether or not executing PCI during hospitalization. As for AMI patients in Taiwan, admission on weekends or weekdays did not have a significant impact on either in-hospital mortality or 1-year cumulative mortality.

Mortality analysis among sepsis patients in and out of intensive care units using the Japanese nationwide medical claims database: a study by the Japan Sepsis Alliance study group

BACKGROUND

A substantial number of sepsis patients require specialized care, including multidisciplinary care, close monitoring, and artificial organ support in the intensive care unit (ICU). However, the efficacy of ICU management on clinical outcomes remains insufficiently researched. Therefore, we tested the hypothesis that ICU admission would increase the survival rate among sepsis patients.

METHODS

We conducted a retrospective study using the nationwide medical claims database of sepsis patients in Japan from 2010 to 2017 with propensity score matching to adjust for baseline imbalances. Patients aged over 20 years, with a combined diagnosis of presumed serious infection and organ failure, were included in this study. The primary outcome studied was the in-hospital mortality among non-ICU and ICU patients. In addition to propensity score matching, we performed a multivariable logistic regression analysis for the primary outcome. As the treatment policy was not extracted from the database, we performed sensitivity analyses to determine mortality differences in adults (20 ≤ age ≤ 64), independent patients, patients without malignant tumors, based on the assumption that treatment intensity is likely to increase in those population.

RESULTS

Among 1,167,901 sepsis patients (974,289 in non-ICU and 193,612 in ICU settings), the unadjusted in-hospital mortality was 22.5% among non-ICU patients and 26.2% among ICU patients (3.7% [95% CI 3.5-3.9]). After propensity score matching, the in-hospital mortality was 29.2% among non-ICU patients and 25.8% among ICU patients ([Formula: see text] 3.4% [95% CI [Formula: see text] 3.7 to [Formula: see text] 3.1]). In-hospital mortality with a multivariable regression analysis ([Formula: see text] 5.0% [95% CI [Formula: see text] 5.2 to [Formula: see text] 4.8]) was comparable with the results of the propensity score matching analysis. In the sensitivity analyses, the mortality differences between non-ICU and ICU in adults, independent patients, and patients without malignant tumors were [Formula: see text] 2.7% [95% CI [Formula: see text] 3.3 to [Formula: see text] 2.2], [Formula: see text] 5.8% [95% CI [Formula: see text] 6.4 to [Formula: see text] 5.2], and [Formula: see text] 1.3% [95% CI [Formula: see text] 1.7 to [Formula: see text] 1.0], respectively.

CONCLUSIONS

Herein, using the nationwide medical claims database, we demonstrated that ICU admission was potentially associated with decreasing in-hospital mortality among sepsis patients. Further investigations are warranted to validate these results and elucidate the mechanisms favoring ICU management on clinical outcomes.

Determinants of regulatory compliance in health and social care services: A systematic review using the Consolidated Framework for Implementation Research

BACKGROUND

The delivery of high quality care is a fundamental goal for health systems worldwide. One policy tool to ensure quality is the regulation of services by an independent public authority. This systematic review seeks to identify determinants of compliance with such regulation in health and social care services.

METHODS

Searches were carried out on five electronic databases and grey literature sources. Quantitative, qualitative and mixed methods studies were eligible for inclusion. Titles and abstracts were screened by two reviewers independently. Determinants were identified from the included studies, extracted and allocated to constructs in the Consolidated Framework for Implementation Research (CFIR). The quality of included studies was appraised by two reviewers independently. The results were synthesised in a narrative review using the constructs of the CFIR as grouping themes.

RESULTS

The search yielded 7,500 articles for screening, of which 157 were included. Most studies were quantitative designs in nursing home settings and were conducted in the United States. Determinants were largely structural in nature and allocated most frequently to the inner and outer setting domains of the CFIR. The following structural characteristics and compliance were found to be positively associated: smaller facilities (measured by bed capacity); higher nurse-staffing levels; and lower staff turnover. A facility's geographic location and compliance was also associated. It was difficult to make findings in respect of process determinants as qualitative studies were sparse, limiting investigation of the processes underlying regulatory compliance.

CONCLUSION

The literature in this field has focused to date on structural attributes of compliant providers, perhaps because these are easier to measure, and has neglected more complex processes around the implementation of regulatory standards. A number of gaps, particularly in terms of qualitative work, are evident in the literature and further research in this area is needed to provide a clearer picture.

Relationship between mental workload and hospital infection in the ICU

BACKGROUND: Nursing is among the most stressful professions. Studies that examine possible factors that influence the mental workload (MWL) of nurses are of fundamental importance, because through these results, efforts can be concentrated on improving their working conditions more efficiently. OBJECTIVE: To investigate the influence of hospital infection on the MWL of nurses in an intensive care unit (ICU). METHOD: Cross-sectional and descriptive study, with a quantitative approach. Three research instruments were used: a sociodemographic questionnaire, the NASA Task Load Index (NASA-TLX) and the Nursing Work Index-Revised Brazilian version (B-NWI-R). The sample consisted of 30 nurses from the ICU of a public hospital in João Pessoa city, Brazil, during the daytime period, and the Spearman correlation test (α= 0,05) was applied to verify associations. RESULTS: There was a high MWL among nurses, with a NASA-TLX weighted average of 66.38 (SD±15.0). Correlations were found between the levels of hospital infection in the ICU and the MWL of the nurses (r = 0.654, p <  0.01); in the nurses’ care of patients with urinary tract infection, the correlation is 0.546, p <  0.01; if care is provided to patients with lung problems, the correlation is 0.563, p <  0.01 The ICU presented a favorable environment to nursing practices, with means lower than 2.5, according to the B-NWI-R. CONCLUSION: The MWL of the nurses was associated with the hospital infection levels of the intensive care sector studied. It was found that the MWL of nurses in relation to hospital infection in the ICU increased by 42.8% . This MWL is impacted by 29.8% when nurses’ care is linked to patients with urinary infection. But if care is provided to patients with lung problems, this percentage rises to 31.7%

Intensive care unit versus high dependency care unit admission after emergency surgery: a nationwide in-patient registry study

BACKGROUND

The appropriate level of postoperative critical care for patients undergoing emergency surgery is unknown. We aimed to assess the outcomes of postoperative patients treated in the intensive care unit (ICU) and high dependency care unit (HDU) after emergency surgery.

METHODS

Analysis of national in-patient registry data in Japan from July 2010 to March 2018, including patients undergoing one of 10 emergency surgeries on the day of hospital admission. The exposures were ICU or HDU admission on the day of surgery. The primary outcome was in-hospital mortality. We performed multivariable logistic regression analysis adjusted for patient and hospital characteristics. Results are presented as n (%) and odds ratios (ORs) with 95% confidence intervals.

RESULTS

We included 158 149 patients from 646 hospitals. Crude in-hospital mortality for each procedure ranged from 168/8583 (2.0%) for cholecystectomy to 2842/12 958 (21.9%) for patients undergoing surgery for traumatic brain injury. Compared with HDU admission, ICU admission was associated with lower in-hospital mortality among the cohorts for medium-mortality risk procedures (procedure-specific mortality 5-15%) (ICU: 8834/73 616 [12.0%] vs HDU: 2586/25 262 [10.2%]; OR=0.90 [0.85-0.96]; P=0.001), and high-mortality risk procedures (procedures-specific mortality >15%) (ICU: 3445/16 334 [21.1%] vs HDU: 996/4613 [21.6%]; OR=0.86 [0.78-0.96]; P=0.005). There were no differences in mortality for low-mortality risk procedures with procedure-specific mortality <5%.

CONCLUSIONS

In this national registry study, postoperative critical care in ICU was associated with lower in-hospital mortality than in HDU for patients undergoing medium-risk and high-risk emergency surgery. Further research is needed to understand the role of critical care for surgical patients.

A Global Survey on Diagnostic, Therapeutic and Preventive Strategies in Intensive Care Unit-Acquired Weakness

Background and Objectives: Intensive care unit-acquired weakness (ICU-AW) is one of the most frequent neuromuscular complications in critically ill patients. We conducted a global survey to evaluate the current practices of diagnostics, treatment and prevention in patients with ICU-AW. Materials and Methods: A pre-survey was created with international experts. After revision, the final survey was endorsed by the European Society of Intensive Care Medicine (ESICM) using the online platform SurveyMonkey®. In 27 items, we addressed strategies of diagnostics, therapy and prevention. An invitation link was sent by email to all ESICM members. Furthermore, the survey was available on the ESICM homepage. Results: A total of 154 healthcare professionals from 39 countries participated in the survey. An ICU-AW screening protocol was used by 20% (28/140) of participants. Forty-four percent (62/141) of all participants reported performing routine screening for ICU-AW, using clinical examination as the method of choice (124/141, 87.9%). Almost 63% (84/134) of the participants reported using current treatment strategies for patients with ICU-AW. The use of treatment and prevention strategies differed between intensivists and non-intensivists regarding the reduction in sedatives (80.0% vs. 52.6%, p = 0.002), neuromuscular blocking agents (76.4% vs. 50%, p = 0.004), corticosteroids (69.1% vs. 37.2%, p < 0.001) and glycemic control regimes (50.9% vs. 23.1%, p = 0.002). Mobilization and physical activity are the most frequently reported treatment strategies for ICU-AW (111/134, 82.9%). The availability of physiotherapists (92/134, 68.7%) and the lack of knowledge about ICU-AW within the medical team (83/134, 61.9%) were the main obstacles to the implementation of the strategies. The necessity to develop guidelines for the screening, diagnosing, treatment and prevention of ICU-AW was recognized by 95% (127/133) of participants. Conclusions: A great heterogeneity regarding diagnostics, treatment and prevention of ICU-AW was reported internationally. Comprehensive guidelines with evidence-based recommendations for ICU-AW management are needed.

ICU Versus High-Dependency Care Unit for Patients With Acute Myocardial Infarction: A Nationwide Propensity Score-Matched Cohort Study

OBJECTIVES

To compare the outcomes of patients with acute myocardial infarction who were treated in ICUs versus high-dependency care units (HDUs).

DESIGN

A nationwide, propensity score-matched, retrospective cohort study of a national administrative inpatient database in Japan from July 2010 to March 2018.

SETTING

Six hundred sixty-six acute-care hospitals with ICU and/or HDU beds covering about 75% of all ICU beds and 70% of all HDU beds in Japan.

PATIENTS

Adult patients who were hospitalized for acute myocardial infarction and admitted to the ICU or HDU on the day of hospital admission. Propensity score-matching analysis was performed to compare the inhospital mortality between patients treated in the ICU and HDU on the day of hospital admission.

INTERVENTIONS

ICU or HDU admission on the day of hospital admission.

MEASUREMENTS AND MAIN RESULTS

Of 135,142 eligible patients, 89,382 (66%) were admitted to the ICU and 45,760 (34%) were admitted to the HDU on the day of admission. After propensity score matching, there was no statistically significant difference in inhospital mortality between the ICU and HDU groups (5.0% vs 5.5%; difference, -0.5%; 95% CI, -1.0% to 0.1%). In the subgroup analyses, inhospital mortality was significantly lower in the ICU group than that in the HDU group among patients with Killip class IV (25.6% vs 28.4%; difference, -2.9%; 95% CI, -5.4% to -0.3%), patients who underwent intubation (40.0% vs 46.6%; difference, -6.6%; 95% CI, -10.6% to -2.7%), and patients who received mechanical circulatory support (21.8% vs 24.7%; difference, -2.8%; 95% CI, -5.5% to -0.2%).

CONCLUSIONS

Critical care in the ICU compared with that in the HDU was not associated with reduced inhospital mortality among the entire cohort of patients with acute myocardial infarction but was associated with reduced inhospital mortality among the subsets of patients with Killip class IV, intubation, or mechanical circulatory support.

Healthcare-associated infections in adult intensive care unit patients: Changes in epidemiology, diagnosis, prevention and contributions of new technologies

Patients in intensive care units (ICUs) are at high risk for healthcare-acquired infections (HAI) due to the high prevalence of invasive procedures and devices, induced immunosuppression, comorbidity, frailty and increased age. Over the past decade we have seen a successful reduction in the incidence of HAI related to invasive procedures and devices. However, the rate of ICU-acquired infections remains high. Within this context, the ongoing emergence of new pathogens, further complicates treatment and threatens patient outcomes. Additionally, the SARS-CoV-2 (COVID-19) pandemic highlighted the challenge that an emerging pathogen provides in adapting prevention measures regarding both the risk of exposure to caregivers and the need to maintain quality of care. ICU nurses hold a special place in the prevention and management of HAI as they are involved in basic hygienic care, steering and implementing quality improvement initiatives, correct microbiological sampling, and aspects antibiotic stewardship. The emergence of more sensitive microbiological techniques and our increased knowledge about interactions between critically ill patients and their microbiota are leading us to rethink how we define HAIs and best strategies to diagnose, treat and prevent these infections in the ICU. This multidisciplinary expert review, focused on the ICU setting, will summarise the recent epidemiology of ICU-HAI, discuss the place of modern microbiological techniques in their diagnosis, review operational and epidemiological definitions and redefine the place of several controversial preventive measures including antimicrobial-impregnated medical devices, chlorhexidine-impregnated washcloths, catheter dressings and chlorhexidine-based mouthwashes. Finally, general guidance is suggested that may reduce HAI incidence and especially outbreaks in ICUs.

Poor power quality is a major barrier to providing optimal care in special neonatal care units (SNCU) in Central India

Background: Approximately 25% of all neonatal deaths worldwide occur in India. The Indian Government has established Special Neonatal Care Units (SNCUs) in district and sub-district level hospitals to reduce neonatal mortality, but mortality rates have stagnated. Reasons include lack of personnel and training and sub-optimal quality of care. The role of medical equipment is critical for the care of babies, but its role in improving neonatal outcomes has not been well studied.  Methods: In a qualitative study, we conducted seven focus group discussions with SNCU nurses and pediatric residents and thirty-five key informant interviews and with pediatricians, residents, nurses, annual equipment maintenance contractors, equipment manufacturers, and Ministry of Health personnel in Maharashtra between December 2019 and November 2020. The goal of the study was to understand challenges to SNCU care. In this paper, we focus on current gaps and future needs for SNCU equipment, quality of the power supply, and use of SNCU equipment. Results: Respondents described a range of issues but highlighted poor power quality as an important cause of equipment malfunction. Other concerns were lack of timely repair that resulted in needed equipment being unavailable for neonatal care. Participants recommended procuring uninterrupted power supply (UPS) to protect equipment, improving quality/durability of equipment to withstand constant use, ensuring regular proactive maintenance for SNCU equipment, and conducting local power audits to discern and address the causes of power fluctuations. Conclusions: Poor power quality and its negative impact on equipment function are major unaddressed concerns of those responsible for the care and safety of babies in SNCUs in Central India. Further research on the power supply and protection of neonatal equipment is needed to determine a cost-effective way to improve access to supportive care in SNCUs and desired improvements in neonatal mortality rates.

Closed-loop oxygen control improves oxygen therapy in acute hypoxemic respiratory failure patients under high flow nasal oxygen: a randomized cross-over study (the HILOOP study)

Background

We aimed to assess the efficacy of a closed-loop oxygen control in critically ill patients with moderate to severe acute hypoxemic respiratory failure (AHRF) treated with high flow nasal oxygen (HFNO).

Methods

In this single-centre, single-blinded, randomized crossover study, adult patients with moderate to severe AHRF who were treated with HFNO (flow rate ≥ 40 L/min with FiO₂ ≥ 0.30) were randomly assigned to start with a 4-h period of closed-loop oxygen control or 4-h period of manual oxygen titration, after which each patient was switched to the alternate therapy. The primary outcome was the percentage of time spent in the individualized optimal SpO₂ range.

Results

Forty-five patients were included. Patients spent more time in the optimal SpO₂ range with closed-loop oxygen control compared with manual titrations of oxygen (96.5 [93.5 to 98.9] % vs. 89 [77.4 to 95.9] %; p < 0.0001) (difference estimate, 10.4 (95% confidence interval 5.2 to 17.2). Patients spent less time in the suboptimal range during closed-loop oxygen control, both above and below the cut-offs of the optimal SpO₂ range, and less time above the suboptimal range. Fewer number of manual adjustments per hour were needed with closed-loop oxygen control. The number of events of SpO₂ < 88% and < 85% were not significantly different between groups.

Conclusions

Closed-loop oxygen control improves oxygen administration in patients with moderate-to-severe AHRF treated with HFNO, increasing the percentage of time in the optimal oxygenation range and decreasing the workload of healthcare personnel. These results are especially relevant in a context of limited oxygen supply and high medical demand, such as the COVID-19 pandemic.

Trial registration The HILOOP study was registered at www.clinicaltrials.gov under the identifier NCT04965844.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13054-022-03970-w.

[Intensive Care Unit-Acquired Weakness : A nationwide survey on diagnostics, monitoring and treatment strategies on German intensive care units]

Hintergrund

Die „Intensive Care Unit-Acquired Weakness“ (ICU-AW) ist eine der häufigsten Ursachen für eine neuromuskuläre Dysfunktion in der Intensivmedizin. Gegenwärtig fehlen evidenzbasierte Empfehlungen zur Diagnostik, zum Monitoring und zu therapeutischen Maßnahmen.

Ziel der Arbeit

Die Erfassung des derzeitigen Vorgehens bei Diagnostik, Monitoring und präventiven und therapeutischen Ansätzen bei der ICU-AW auf deutschen Intensivstationen.

Material und Methoden

Onlinebefragung von 448 Mitgliedern des Wissenschaftlichen Arbeitskreises Intensivmedizin (WAKI) und des Wissenschaftlichen Arbeitskreises Neuroanästhesie (WAKNA).

Ergebnisse

Insgesamt wurden 68/448 (15,2 %) Fragebogen ausgewertet. Bei 13,4 % (9/67) der Befragten existiert ein strukturiertes diagnostisches Vorgehen zur Detektion der ICU-AW. Für Screening (60/68; 88,2 %) und Verlaufsbeurteilung (57/65; 87,7 %) wird die klinische Untersuchung präferiert. Etablierte Scores, wie der „Medical Research Council sum score“ (MRC-SS) spielen für Screening und Verlaufskontrolle der ICU-AW eine untergeordnete Rolle (7/68; 10,3 % und 7/65; 10,8 %). Mobilisation (45/68; 66,2 %) und Sedativareduktion (38/68; 55,9 %) stellen die häufigsten präventiven und therapeutischen Ansätze dar. Ein Mangel an Physiotherapeuten (64/68; 94,1 %) und Pflegekräften (57/68; 83,8 %) wird als Hauptdefizit bei der Versorgung von Patienten mit ICU-AW identifiziert. Insgesamt 91,2 % (62/68) der Befragten befürworten die Erstellung evidenzbasierter Empfehlungen zur Diagnostik, zum Monitoring und zu therapeutischen Ansätzen bei ICU-AW.

Diskussion

Ein einheitliches Konzept für Diagnostik, Monitoring, Prävention und Therapie der ICU-AW auf deutschen Intensivstationen fehlt weitgehend. Innovative diagnostische Ansätze könnten in Zukunft helfen, Patienten mit einem hohem Risiko für eine ICU-AW frühzeitig zu detektieren, präventive Maßnahmen einzuleiten sowie wertvolle prognostische Informationen zu gewinnen.

Zusatzmaterial online

Die Online-Version dieses Beitrags (10.1007/s00101-022-01089-9) enthält den der Studie zugrunde liegenden Fragebogen.

Association of community-level social vulnerability with US acute care hospital intensive care unit capacity during COVID-19

The COVID-19 pandemic has placed unprecedented stress on US acute care hospitals, leading to overburdened ICUs. It remains unknown if increased COVID-19 ICU occupancy is crowding out non-COVID-related care and whether hospitals in vulnerable communities may be more susceptible to ICUs reaching capacity. Using facility-level hospitalization data, we conducted a retrospective observational cohort study of 1753 US acute care hospitals reporting to the US Department of Health and Human Services Protect database from September 4, 2020 to February 25, 2021. 63% of hospitals reached critical ICU capacity for at least two weeks during the study period, and the surge of COVID-19 cases appeared to be crowding out non-COVID-19-related intensive care needs. Hospitals in the South (OR = 3.31, 95% CI OR 2.31–4.78) and West (OR = 2.28, 95% CI OR 1.51–3.46) were more likely to reach critical capacity than those in the Northeast, and hospitals in areas with the highest social vulnerability were more than twice as likely to reach capacity as those in the least vulnerable areas (OR = 2.15, 95% CI OR 1.41–3.29). The association between social vulnerability and critical ICU capacity highlights underlying structural inequities in health care access and provides an opportunity for policymakers to take action to prevent strained ICU capacity from compounding COVID-19 inequities.

Association of Surge Conditions with Mortality Among Critically Ill Patients with COVID-19

Objective

To determine whether surge conditions were associated with increased mortality.

Design

Multicenter cohort study.

Setting

U.S. ICUs participating in STOP-COVID.

Patients

Consecutive adults with COVID-19 admitted to participating ICUs between March 4 and July 1, 2020.

Interventions

None

Measurements and Main Results

The main outcome was 28-day in-hospital mortality. To assess the association between admission to an ICU during a surge period and mortality, we used two different strategies: (1) an inverse probability weighted difference-in-differences model limited to appropriately matched surge and non-surge patients and (2) a meta-regression of 50 multivariable difference-in-differences models (each based on sets of randomly matched surge- and non-surge hospitals). In the first analysis, we considered a single surge period for the cohort (March 23 – May 6). In the second, each surge hospital had its own surge period (which was compared to the same time periods in matched non-surge hospitals).

Our cohort consisted of 4342 ICU patients (average age 60.8 [sd 14.8], 63.5% men) in 53 U.S. hospitals. Of these, 13 hospitals encountered surge conditions. In analysis 1, the increase in mortality seen during surge was not statistically significant (odds ratio [95% CI]: 1.30 [0.47-3.58], p = .6). In analysis 2, surge was associated with an increased odds of death (odds ratio 1.39 [95% CI, 1.34-1.43], p < .001).

Conclusions

Admission to an ICU with COVID-19 in a hospital that is experiencing surge conditions may be associated with an increased odds of death. Given the high incidence of COVID-19, such increases would translate into substantial excess mortality.

Intensive care unit versus high-dependency care unit for patients with acute heart failure: a nationwide propensity score-matched cohort study

Background

A structure and staffing model similar to that in general intensive care unit (ICUs) is applied to cardiac intensive care unit (CICUs) for patients with acute heart failure. However, there is limited evidence on the structure and staffing model of CICUs. The present study aimed to assess whether critical care for patients with acute heart failure in the ICUs is associated with improved outcomes than care in the high-dependency care units (HDUs), the hospital units in which patient care levels and costs are between the levels found in the ICU and general ward.

Methods

This nationwide, propensity score-matched, retrospective cohort study was performed using a national administrative inpatient database in Japan. We identified all patients who were hospitalized for acute heart failure and admitted to the ICU or HDU on the day of hospital admission from April 2014 to March 2019. Propensity score-matching analysis was performed to compare the in-hospital mortality between acute heart failure patients treated in the ICU and HDU on the day of hospital admission.

Results

Of 202,866 eligible patients, 78,646 (39%) and 124,220 (61%) were admitted to the ICU and HDU, respectively, on the day of admission. After propensity score matching, there was no statistically significant difference in in-hospital mortality between patients who were admitted to the ICU and HDU on the day of admission (10.7% vs. 11.4%; difference, − 0.6%; 95% confidence interval, − 1.5% to 0.2%). In the subgroup analyses, there was a statistically significant difference in in-hospital mortality between the ICU and HDU groups among patients receiving noninvasive ventilation (9.4% vs. 10.5%; difference, − 1.0%; 95% confidence interval, − 1.9% to − 0.1%) and patients receiving intubation (32.5% vs. 40.6%; difference, − 8.0%; 95% confidence interval, − 14.5% to − 1.5%). There were no statistically significant differences in other subgroup analyses.

Conclusions

Critical care in ICUs was not associated with lower in-hospital mortality than critical care in HDUs among patients with acute heart failure. However, critical care in ICUs was associated with lower in-hospital mortality than critical care in HDUs among patients receiving noninvasive ventilation and intubation.

Supplementary Information

The online version contains supplementary material available at 10.1186/s40560-021-00592-2.

Staffing critical care with nurses amid the COVID-19 crisis: Strategies and plans

AIM

To describe a nursing staffing surge model in critical care units that can be used during a pandemic or crisis. This model may give useful guidance for hospitals or centers that must immediately react in response to the devastating challenges introduced by disease outbreaks.

BACKGROUND

During the COVID-19 pandemic, many hospitals were challenged to maintain the quality of care and safe practice in critical care units while accommodating the daily rapidly increasing number of infected cases that needed critical care. The nursing staffing shortage in critical care units and its consequences were among the top issues to deal with.

METHOD

This is a descriptive study about our experience in preparing for nursing staffing in critical care as a part of the COVID-19 surge plan. We have used evidence-based strategies to design our team-based model for staffing during the COVID-19 pandemic.

RESULTS

The team-based model for staffing during the COVID-19 pandemic had shown success in dealing with the acute shortage of nursing staff in critical care units. We had implemented other additional supportive strategies to help enhance this staffing.

CONCLUSION

With the support of available evidence-based resources and on-the-fly preparation and training, we were able to augment the tremendous increase in patient influx during the pandemic using the team-based model.

IMPLICATIONS FOR NURSING MANAGEMENT

The team-based approach and other strategies included in this article can help support critical care units with staff during crises. However, we strongly recommend developing a nursing deployment policy that makes staff redeployment and re-allocation smoother, whenever needed.

The impact of patient delirium in the intensive care unit: patterns of anxiety symptoms in family caregivers

BACKGROUND

The purpose of this study was to examine the association of patient delirium in the intensive care unit (ICU) with patterns of anxiety symptoms in family caregivers when delirium was determined by clinical assessment and family-administered delirium detection.

METHODS

In this cross-sectional study, consecutive adult patients anticipated to remain in the ICU for longer than 24 h were eligible for participation given at least one present family caregiver (e.g., spouse, friend) provided informed consent (to be enrolled as a dyad) and were eligible for delirium detection (i.e., Richmond Agitation-Sedation Scale score ≥ - 3). Generalized Anxiety Disorder-7 (GAD-7) was used to assess self-reported symptoms of anxiety. Clinical assessment (Confusion Assessment Method for ICU, CAM-ICU) and family-administered delirium detection (Sour Seven) were completed once daily for up to five days.

RESULTS

We included 147 family caregivers; the mean age was 54.3 years (standard deviation [SD] 14.3 years) and 74% (n = 129) were female. Fifty (34% [95% confidence interval [CI] 26.4-42.2]) caregivers experienced clinically significant symptoms of anxiety (median GAD-7 score 16.0 [interquartile range 6]). The most prevalent symptoms of anxiety were "Feeling nervous, anxious or on edge" (96.0% [95%CI 85.2-99.0]); "Not being able to stop or control worrying" (88.0% [95%CI 75.6-94.5]; "Worrying too much about different things" and "Feeling afraid as if something awful might happen" (84.0% [95%CI 71.0-91.8], for both). Family caregivers of critically ill adults with delirium were significantly more likely to report "Worrying too much about different things" more than half of the time (CAM-ICU, Odds Ratio [OR] 2.27 [95%CI 1.04-4.91]; Sour Seven, OR 2.28 [95%CI 1.00-5.23]).

CONCLUSIONS

Family caregivers of critically ill adults with delirium frequently experience clinically significant anxiety and are significantly more likely to report frequently worrying too much about different things. Future work is needed to develop mental health interventions for the diversity of anxiety symptoms experienced by family members of critically ill patients.

TRIAL REGISTRATION

This study is registered on ClinicalTrials.gov ( https://clinicaltrials.gov/ct2/show/NCT03379129 ).

A Review of Mortality Risk Prediction Models in Smartphone Applications

Healthcare professionals in healthcare systems need access to freely available, real-time, evidence-based mortality risk prediction smartphone applications to facilitate resource allocation. The objective of this study is to evaluate the quality of smartphone mobile health applications that include mortality prediction models, and corresponding information quality. We conducted a systematic review of commercially available smartphone applications in Google Play for Android, and iTunes for iOS smartphone applications. We performed initial screening, data extraction, and rated smartphone application quality using the Mobile Application Rating Scale: user version (uMARS). The information quality of smartphone applications was evaluated using two patient vignettes, representing low and high risk of mortality, based on critical care data from the Medical Information Mart for Intensive Care (MIMIC) III database. Out of 3051 evaluated smartphone applications, 33 met our final inclusion criteria. We identified 21 discrete mortality risk prediction models in smartphone applications. The most common mortality predicting models were Sequential Organ Failure Assessment (SOFA) (n = 15) and Acute Physiology and Clinical Health Assessment II (n = 13). The smartphone applications with the highest quality uMARS scores were Observation-NEWS 2 (4.64) for iOS smartphones, and MDCalc Medical Calculator (4.75) for Android smartphones. All SOFA-based smartphone applications provided consistent information quality with the original SOFA model for both the low and high-risk patient vignettes. We identified freely available, high-quality mortality risk prediction smartphone applications that can be used by healthcare professionals to make evidence-based decisions in critical care environments.

Healthcare professional views on barriers to implementation of evidence-based practice in prevention of ventilator-associated events: A qualitative descriptive study

OBJECTIVE

To explore health professional views of barriers to the use of evidence-based practice to prevent ventilator-associated events in intensive care units.

DESIGN

A qualitative descriptive study was conducted with nurses and doctors with more than six months experience caring for mechanically ventilated patients.

SETTING

The study was conducted in two intensive care units, in large metropolitan health services in Victoria, Australia.

METHODS

Individual semi-structured interviews were undertaken with 20 participants (16 nurses and 4 doctors) in 2019. Purposive sampling method was used until data saturation was reached. The interviews were held at the hospital in a private room away from their place of employment. The interview data were analysed using thematic analysis.

FINDINGS

Four major themes were inductively identified from nine subthemes: i) prioritising specific situations, ii) inadequate use of evidence to underpin practice, iii) perception of inadequate staffing and equipment and, iv) inadequate training and knowledge of evidence-based guidelines.

CONCLUSIONS

These themes helped to explain previously reported deficits in nurses' knowledge of and adherence to evidence-based practice in intensive care. Findings suggest the need for a well-established policy to underpin practice. The barriers faced by nurses and doctors in preventing ventilator associated events need to be addressed to optimise quality of patient care in intensive care units.

Resource-rich Intensive Care Units vs. Standard Intensive Care Units on Patient Mortality: A Nationwide Inpatient Database Study

Introduction

In this present study, we aimed to assess whether care in resource-rich intensive care unit (ICU) was associated with lower ICU mortality compared with care in standard ICU.

Methods

This retrospective cohort study used administrative data that are routinely collected in Japan. Using the Japanese Diagnosis Procedure Combination inpatient database, we identified patients aged >15 years who were admitted to the ICU from April 2016 to March 2019. We defined resource-rich ICUs as ICUs with two or more intensivists as full-time employees, ≥20 m² per ICU bed, and a medical engineer in the hospital 24 hours per day; other ICUs were categorized as standard ICUs. The primary outcome was ICU mortality. A generalized estimating equation approach with ICUs as the clusters was used to compare ICU mortality between the two groups.

Results

Of the 789,630 eligible patients from 458 ICUs, 237,138 (30%) were treated in the 111 resource-rich ICUs, whereas 552,492 (70%) were treated in the 347 standard ICUs. The crude ICU mortality rate was 3.6% (8443/237,138) among patients admitted to resource-rich ICUs, while it was 4.3% (23,490/552,492) among those admitted to standard ICUs. The results of the generalized estimating equation analysis showed that patients treated in resource-rich ICUs tended to have lower ICU mortality compared to patients treated in standard ICUs (difference, -0.4%; 95% confidence interval, -0.8%-0.0%).

Conclusions

The findings of this nationwide study suggest that, compared with care in standard ICUs, care in resource-rich ICUs is associated with lower ICU mortality. This study showed the overall effect of treatment in hospitals with resource-rich ICUs including intensivist staffing and greater hospital resources. Further studies are required to assess the effects of organizational factors on mortality.

Primary palliative care integrated model in paediatric ICU: an international cross-sectional study

OBJECTIVES

Numbers are rising of chronically and critically ill, technology-dependent children, who are admitted to paediatric intensive care units (PICUs). An integrated model of care (IMOC), that combines paediatric critical care and primary paediatric palliative care (PPC), in which either approach varies depending on the disease trajectory and is provided by the critical care team, might be a fundamental component of the best available standard of care for patients with life-threatening conditions. The objective of this study is to assess how PICUs around the world, implement an IMOC.

METHODS

International multicentre cross-sectional observational study. Data was gathered from 34 PICUs from 18 countries in the Americas, Europe, Asia and Africa. Provision of primary PPC was studied for each child admitted at the PICU. We evaluated score differences in each domain of the Initiative for Paediatric Palliative Care (IPPC) curriculum with multilevel generalised linear models.

RESULTS

High-income country (HIC) units made up 32.4% of the sample, upper-middle income countries (UMICs) 44.1%, lower-middle income/lower income countries (LMIC/LICs) 23.5%. HICs had four statistically significantly higher IPPC scores compared with UMICs (domains: 1 holistic care; 2 family support, 3B family involvement; 6B grief/bereavement healthcare provider support) and two compared with LMIC/LICs (domains: 6A grief/bereavement family support; 6B grief/bereavement healthcare provider support).HICs had a statistically significant overall higher IPPC score than UMICs. Adjusting for patient/centre characteristics, shorter shifts and multiple comorbidities were associated with higher IPPC scores.

CONCLUSIONS

All centres offered some PPC provision and partially applied an IMOC. These results are encouraging, however, differences related to income and patients/unit evidence opportunities for improvement.

TRIAL REGISTRATION NUMBER

ISRCTN12556149.

Quality of Heart Failure Care in the Intensive Care Unit

Patients with heart failure (HF) who are seen in an intensive care unit (ICU) manifest the highest-risk, most complex and most resource-intensive disease states. These patients account for a large relative proportion of days spent in an ICU. The paradigms by which critical care is provided to patients with HF are being reconsidered, including consideration of various multidisciplinary ICU staffing models and the development of acute-response teams. Traditional HF quality initiatives have centered on the peri- and postdischarge period in attempts to improve adherence to guideline-directed therapies and reduce readmissions. There is a compelling rationale for expanding high-quality efforts in treating patients with HF who are receiving critical care so we can improve outcomes, reduce preventable harm, improve teamwork and resource use, and achieve high health-system performance. Our goal is to answer the following question: For a patient with HF in the ICU, what is required for the provision of high-quality care? Herein, we first review the epidemiology of HF syndromes in the ICU and identify relevant critical care and quality stakeholders in HF. We next discuss the tenets of high-quality care for patients with HF in the ICU that will optimize critical care outcomes, such as ICU staffing models and evidence-based management of cardiac and noncardiac disease. We discuss strategies to mitigate preventable harm, improve ICU culture and conduct outcomes review, and we conclude with our summative vision of high-quality of ICU care for patients with HF; our vision includes clinical excellence, teamwork and ICU culture.

Intensive care unit versus high-dependency care unit for mechanically ventilated patients with pneumonia: a nationwide comparative effectiveness study

Background

Many mechanically ventilated patients in Japan are treated in high-dependency care units (HDUs) rather than intensive care units (ICUs). HDUs can provide intermediate-level care with reduced costs; however, there is limited evidence on whether mechanically ventilated patients should be treated in the ICU or HDU.

Methods

This was a comparative effectiveness study using a nationwide administrative database in Japan. We identified mechanically ventilated patients with pneumonia in ICU or HDU on the day of admission in the Japanese Diagnosis Procedure Combination inpatient database from April 2014 to March 2019. The primary outcome was 30-day in-hospital mortality. Propensity score matching analysis was performed to compare this outcome between patients treated in the ICU and HDU. The robustness of the analyses was evaluated with multivariable regression, overlap weighting, and instrumental variable analyses.

Findings

Of 14,859 mechanically ventilated patients with pneumonia, 7,528 (51%) were treated in the ICU and 7,331 (49%) were treated in the HDU. After propensity score matching, patients treated in the ICU had significantly lower 30-day in-hospital mortality than did those treated in the HDU (24.0% vs. 31.2%; difference, −7.2%; 95% confidence interval, −10.0% to −4.4%). The multivariable regression, overlap weighting, and instrumental variable analyses showed a similar direction and magnitude of association.

Interpretation

Critical care for mechanically ventilated patients with pneumonia in the ICU was associated with a 7.2% decrease in 30-day in-hospital mortality vs. care in the HDU. Residual confounding may still play a role in the effect estimates.

Funding

This study received funding from Ministry of Health, Labour and Welfare, Japan, and Ministry of Education, Culture, Sports, Science and Technology, Japan.

Implementation of the MATRIX Staffing Grid Improves Nurse Satisfaction With Rehabilitation Unit Staffing

ABSTRACT

BACKGROUND: Information on nurse satisfaction and unit acuity is scarce in the literature. The purpose of this study is to evaluate the effect of the MATRIX Staffing Grid (MSG) on nurse assignment satisfaction in a 20-bed inpatient rehabilitation facility. METHODS: Prospective systematic implementation study of the MSG occurred in 5 phases: development, baseline, run-in, implementation, and sustainability. Pretest/posttest nursing satisfaction data were analyzed using Wilcoxon-Mann-Whitney tests. RESULTS: Analysis of 128 satisfaction surveys demonstrated that the median total satisfaction score increased by 35% after MSG implementation (P < .05), with no change in patient satisfaction or adverse event rates. CONCLUSION: A systematic approach to implementation of the MSG evidence-based practice significantly improved nursing satisfaction with patient assignment in a way that addressed specific needs. The MSG has now been adopted into practice at our institution. The MSG may be feasible for implementation in inpatient rehabilitation units to improve staffing satisfaction.

Outcomes sensitive to critical care nurse staffing levels: A systematic review

OBJECTIVE

To determine associations between variations in registered nurse staffing levels in adult critical care units and outcomes such as patient, nurse, organisational and family outcomes.

METHODS

We published and adhered to a protocol, stored in an open access repository and searched for quantitative studies written in the English language and held in CINAHL Plus, MEDLINE, PsycINFO, SCOPUS and NDLTD databases up to July 2020. Three authors independently extracted data and critically appraised papers meeting the inclusion criteria. Results are summarised in tables and discussed in terms of strength of internal validity. A detailed review of the two most commonly measured outcomes, patient mortality and nosocomial infection, is also presented.

RESULTS

Our search returned 7960 titles after duplicates were removed; 55 studies met the inclusion criteria. Studies with strong internal validity report significant associations between lower levels of critical care nurse staffing and increased odds of both patient mortality (1.24-3.50 times greater) and nosocomial infection (3.28-3.60 times greater), increased hospital costs, lower nurse-perceived quality of care and lower family satisfaction. Meta-analysis was not feasible because of the wide variation in how both staffing and outcomes were measured.

CONCLUSIONS

A large number of studies including several with high internal validity provide evidence that higher levels of critical care nurse staffing are beneficial to patients, staff and health services. However, inconsistent approaches to measurement and aggregation of staffing levels reported makes it hard to translate findings into recommendation for safe staffing in critical care.

The impact of nurse staffing levels on nursing-sensitive patient outcomes: a multilevel regression approach

The goal of this study is to provide empirical evidence of the impact of nurse staffing levels on seven nursing-sensitive patient outcomes (NSPOs) at the hospital unit level. Combining a very large set of claims data from a German health insurer with mandatory quality reports published by every hospital in Germany, our data set comprises approximately 3.2 million hospital stays in more than 900 hospitals over a period of 5 years. Accounting for the grouping structure of our data (i.e., patients grouped in unit types), we estimate cross-sectional, two-level generalized linear mixed models (GLMMs) with inpatient cases at level 1 and units types (e.g., internal medicine, geriatrics) at level 2. Our regressions yield 32 significant results in the expected direction. We find that differentiating between unit types using a multilevel regression approach and including postdischarge NSPOs adds important insights to our understanding of the relationship between nurse staffing levels and NSPOs. Extending our main model by categorizing inpatient cases according to their clinical complexity, we are able to rule out hidden effects beyond the level of unit types.

Workforce management and patient outcomes in the intensive care unit during the COVID-19 pandemic and beyond: a discursive paper

AIMS

To highlight the need for the development of effective and realistic workforce strategies for critical care nurses, in both a steady state and pandemic.

BACKGROUND

In acute care settings, there is an inverse relationship between nurse staffing and iatrogenesis, including mortality. Despite this, there remains a lack of consensus on how to determine safe staffing levels. Intensive care units (ICU) provide highly specialised complex healthcare treatments. In developed countries, mortality rates in the ICU setting are high and significantly varied after adjustment for diagnosis. The variability has been attributed to systems, patient and provider issues including the workload of critical care nurses.

DESIGN

Discursive paper.

FINDINGS

Nursing workforce is the single most influential mediating variable on ICU patient outcomes. Numerous systematic reviews have been undertaken in an effort to quantify the effect of critical care nurses on mortality and morbidity, invariably leading to the conclusion that the association is similar to that reported in acute care studies. This is a consequence of methodological limitations, inconsistent operational definitions and variability in endpoint measures. We evaluated the impact inadequate measurement has had on capturing relevant critical care data, and we argue for the need to develop effective and realistic ICU workforce measures.

CONCLUSION

COVID-19 has placed an unprecedented demand on providing health care in the ICU. Mortality associated with ICU admission has been startling during the pandemic. While ICU systems have largely remained static, the context in which care is provided is profoundly dynamic and the role and impact of the critical care nurse needs to be measured accordingly. Often, nurses are passive recipients of unplanned and under-resourced changes to workload, and this has been brought into stark visibility with the current COVID-19 situation. Unless critical care nurses are engaged in systems management, achieving consistently optimal ICU patient outcomes will remain elusive.

RELEVANCE TO CLINICAL PRACTICE

Objective measures commonly fail to capture the complexity of the critical care nurses' role despite evidence to indicate that as workload increases so does risk of patient mortality, job stress and attrition. Critical care nurses must lead system change to develop and evaluate valid and reliable workforce measures.

Targeted Minimal Staff-to-Patient Ratios Are Unachievable - A Nationwide Survey in German ICUs During the COVID-19 Pandemic

Introduction

Adequate staffing in the intensive care units (ICUs) is the most important factor to provide optimal care and ensure favorable outcomes in critically ill patients. Recently, the need for ICU beds has reached unprecedented levels and the management and treatment of critically ill patients has been in focus. The aim of the study was to assess the targeted and actual nurse-to-patient (NPR) and physician-to-patient ratios (PPR) regarding patients with and without COVID-19.

Methods

We conducted a nationwide online survey assessing the standard of care in German ICUs treating patients with COVID-19. We asked questions regarding targeted PPR and NPR and their implementation in daily clinical practice to heads of German ICU departments.

Results

We received 244 responses of which 171 were eligible for final analysis. Targeted median PPR ratio was 8 [interquartile range (IQR) = 4] and targeted NPR was 2 (IQR = 1). For COVID-19 patients, the median targeted PPR was 6 (IQR = 2) and the median targeted NPR was 2 (IQR = 0). Targeted PPRs were rarely met by 15.2% and never met by 3.5% of responding institutions. Targeted NPRs were rarely met in 32.2% and never in 5.3% of responding institutions.

Conclusion

In contrast to PPR, targeted NPRs were largely unattainable in German ICUs. Our results raise concern in view of studies linking worse outcomes in critically ill patients to suboptimal NPRs. This warrants further health policy efforts regarding optimal staffing in the ICU.

Decision support tool for hospital resource allocation during the COVID-19 pandemic

The SARS-CoV-2 (COVID-19) pandemic has placed unprecedented demands on entire health systems and driven them to their capacity, so that health care professionals have been confronted with the difficult problem of ensuring appropriate staffing and resources to a high number of critically ill patients. In light of such high-demand circumstances, we describe an open web-accessible simulation-based decision support tool for a better use of finite hospital resources. The aim is to explore risk and reward under differing assumptions with a model that diverges from most existing models which focus on epidemic curves and related demand of ward and intensive care beds in general. While maintaining intuitive use, our tool allows randomized "what-if" scenarios which are key for real-time experimentation and analysis of current decisions' down-stream effects on required but finite resources over self-selected time horizons. While the implementation is for COVID-19, the approach generalizes to other diseases and high-demand circumstances.

Hospital Magnet Status Associates With Inpatient Safety in Parkinson Disease

ABSTRACT

BACKGROUND: Persons with Parkinson disease (PD) have complex care needs that may benefit from enhanced nursing care provided in Magnet-designated hospitals. Our primary objective was to determine whether an association exists between hospital Magnet status and patient safety events for PD inpatients in the United States. METHODS: We conducted a retrospective cohort study using the Nationwide Inpatient Sample and Agency for Healthcare Research and Quality databases from 2000 to 2010. Parkinson disease diagnosis and demographic variables were retrieved, along with Magnet designation and other hospital characteristics. Inpatient mortality and preventable adverse events in hospitals with and without Magnet status were then compared using relevant Agency for Healthcare Research and Quality patient safety indicators. RESULTS: Between 2000 and 2010, 493 760 hospitalizations among PD patients were identified. Of those, 40 121 (8.1%) occurred at one of 389 Magnet hospitals. When comparing PD patients in Magnet versus non-Magnet hospitals, demographic characteristics were similar. Multivariate regression models adjusting for patient and hospital characteristics identified a 21% reduction in mortality among PD inpatients in Magnet hospitals (adjusted odds ratio [AOR], 0.79; 95% confidence interval [CI], 0.74-0.85). PD inpatients in Magnet hospitals also had a lower odds of experiencing any patient safety indicator (AOR, 0.74; 95% CI, 0.68-0.79), pressure ulcers (AOR, 0.60; 95% CI, 0.55-0.67), death from a low mortality condition (AOR, 0.74; 95% CI, 0.68-0.79), and a higher odds of postoperative bleeding (AOR, 1.45; 95% CI, 1.04-2.04). CONCLUSIONS: PD patients had a reduced risk of inpatient mortality and several nursing-sensitive patient safety events, highlighting the possible benefits of Magnet status on inpatient safety in PD.

Challenges Facing the Nursing Profession in Saudi Arabia: An Integrative Review

There is a paucity of recent literature identifying the issues facing the nursing profession in Saudi Arabia. The aim of this integrative review is to highlight the ongoing challenges facing the nursing profession in Saudi Arabia despite attempts to make a difference and suggests recommendations for the future. Literature published from 2000 to 2020, inclusive, relevant for nursing challenges in Saudi Arabia was accessed and reviewed from multiple sources. In Saudi Arabia, inadequate numbers of Saudi nurses have prompted an increase in recruitment of expatriate nurses. This has created its own issues including, retention, lack of competency in English and Arabic, as well as Arabic cultural aspects, insufficient experience, and a high workload. The result is job dissatisfaction and increased attrition as these nurses prefer to move to more developed countries. For national nurses, the issues are the need to recruit more and retain these nurses. There are a range of cultural factors that contribute to these issues with national nurses. There is a need to improve the image of nursing to recruit more Saudi nurses as well as addressing issues in education and work environment. For expatriate nurses there is a need for a better recruitment processes, a thorough program of education to improve knowledge and skills to equip them to work and stay in Saudi. There is also a need for organizational changes to be made to increase the job satisfaction and retention of nurses generally. Healthcare in Saudi Arabia also needs leaders to efficiently manage the various issues associated with the nursing workforce challenges.

Mortality of major cardiovascular emergencies among patients admitted to hospitals on weekends as compared with weekdays in Taiwan

Background

Several studies have found a so-called weekend effect that patients admitted at the weekends had worse clinical outcomes than patients admitted at the weekdays. We performed this retrospective cohort study to explore the weekend effect in four major cardiovascular emergencies in Taiwan.

Methods

The Taiwan National Health Insurance (NHI) claims database between 2005 and 2015 was used. We extracted 3811 incident cases of ruptured aortic aneurysm, 184,769 incident cases of acute myocardial infarction, 492,127 incident cases of ischemic stroke, and 15,033 incident cases of pulmonary embolism from 9,529,049 patients having at least one record of hospitalization in the NHI claims database within 2006 ~ 2014. Patients were classified as weekends or weekdays admission groups. Dates of in-hospital mortality and one-year mortality were obtained from the Taiwan National Death Registry.

Results

We found no difference in in-hospital mortality between weekend group and weekday group in patients with ruptured aortic aneurysm (45.4% vs 45.3%, adjusted odds ratio [OR] 1.01, 95% confidence interval [CI] 0.87–1.17, p = 0.93), patients with acute myocardial infarction (15.8% vs 16.2%, adjusted OR 0.98, 95% CI 0.95–1.00, p = 0.10), patients with ischemic stroke (4.1% vs 4.2%, adjusted OR 0.99, 95% CI 0.96–1.03, p = 0.71), and patients with pulmonary embolism (14.6% vs 14.6%, adjusted OR 1.02, 95% CI 0.92–1.15, p = 0.66). The results remained for 1 year in all the four major cardiovascular emergencies.

Conclusions

We found no difference in either short-term or long-term mortality between patients admitted on weekends and patients admitted on weekdays in four major cardiovascular emergencies in Taiwan.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12913-021-06553-7.

Partnering With Family Members to Detect Delirium in Critically Ill Patients

OBJECTIVES

To evaluate the diagnostic accuracy of family-administered tools to detect delirium in critically ill patients.

DESIGN

Diagnostic accuracy study.

SETTING

Large, tertiary care academic hospital in a single-payer health system.

PATIENTS

Consecutive, eligible patients with at least one family member present (dyads) and a Richmond Agitation-Sedation Scale greater than or equal to -3, no primary direct brain injury, the ability to provide informed consent (both patient and family member), the ability to communicate with research staff, and anticipated to remain admitted in the ICU for at least a further 24 hours to complete all assessments at least once.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

Family-administered delirium assessments (Family Confusion Assessment Method and Sour Seven) were completed once daily. A board-certified neuropsychiatrist and team of ICU research nurses conducted the reference standard assessments of delirium (based on Diagnostic and Statistical Manual for Mental Disorders, Fifth Edition, criteria) once daily for a maximum of 5 days. The mean age of the 147 included patients was 56.1 years (SD, 16.2 yr), 61% of whom were male. Family members (n = 147) were most commonly spouses (n = 71, 48.3%) of patients. The area under the receiver operating characteristic curve on the Family Confusion Assessment Method was 65.0% (95% CI, 60.0-70.0%), 71.0% (95% CI, 66.0-76.0%) for possible delirium (cutpoint of 4) on the Sour Seven and 67.0% (95% CI, 62.0-72.0%) for delirium (cutpoint of 9) on the Sour Seven. These area under the receiver operating characteristic curves were lower than the Intensive Care Delirium Screening Checklist (standard of care) and Confusion Assessment Method for ICU. Combining the Family Confusion Assessment Method or Sour Seven with the Intensive Care Delirium Screening Checklist or Confusion Assessment Method for ICU resulted in area under the receiver operating characteristic curves that were not significantly better, or worse for some combinations, than the Intensive Care Delirium Screening Checklist or Confusion Assessment Method for ICU alone. Adding the Family Confusion Assessment Method and Sour Seven to the Intensive Care Delirium Screening Checklist and Confusion Assessment Method for ICU improved sensitivity at the expense of specificity.

CONCLUSIONS

Family-administered delirium detection is feasible and has fair, but lower diagnostic accuracy than clinical assessments using the Intensive Care Delirium Screening Checklist and Confusion Assessment Method for ICU. Family proxy assessments are essential for determining baseline cognitive function. Engaging and empowering families of critically ill patients warrant further study.

Nursing care factors influencing patients' outcomes in the intensive care unit: Findings from a rapid review

Aims

To examine the nursing care factors investigated regarding their influence on outcomes of critically ill patients.

Background

A large number of studies have considered patients' outcomes as sensitive to nursing practice in intensive care unit environments. However, no summary of nursing factors influencing these outcomes has been provided.

Design

Rapid review, following the seven‐stage process outlined by Tricco and colleagues.

Data Sources

Articles published up to March 2020 were identified in MEDLINE (via PubMed), Cumulative Index to Nursing and Allied Health Literature (CINAHL) and Scopus databases.

Review Methods

Eligibility of studies was first assessed at the title and abstracts level. Study inclusion was then established by two researchers by analysing the full texts.

Results

A total of 93 studies were included, with a total of 21 nursing care factors documented. At the structural level, nursing factors have been investigated at the organizational and at the personnel level. At the process level, nurse‐led programmes, independent nursing interventions and nurse behaviours have been investigated to date.

Conclusion

The set of nursing factors that emerged can be used in future research to improve poorly developed areas and to accumulate further evidence through additional studies, both at managerial and practice levels.

What is already known about this topic?

Thirty‐five nursing‐sensitive outcomes capable of being used to measure the quality of care in the intensive care unit have been identified to date.

Several nursing care factors in structural and process dimensions have been documented as having an influence on the outcomes of critically ill patients.

What this paper adds:

Many interventions have been assessed in relation to nursing outcomes, more often at the process than at structural levels.

Specifically, a total of 21 nursing factors have been studied to date in the context of intensive care units, divided into structure (organizational and personnel) and process (nurse‐led programmes, independent nursing interventions and behaviours) dimensions.

The implications of this paper

The set of nursing factors that emerged can be considered as a basis for further research, especially regarding poorly developed areas.

Emergent nursing care factors can be used as a blueprint to design and develop educational programmes both at under‐ and postgraduate levels.

At the managerial levels, both structure and process dimensions of nursing care are capable of affecting outcomes and could be used to inform decision‐making.

Effect of Nursing Workload in Intensive Care Units

Nursing work efforts are important in providing sound healthcare services, especially in the intensive care units (ICU). Complications and adverse events are more liable to occur among patients in the ICU and these patients require more attention and nursing care. Most of the research in this field is mainly focused on the effect of staffing and its correlation to patient safety and satisfaction. Previous studies also showed that reduced nursing staffing was significantly associated with the development of pneumonia in ICU patients who needed more nursing requirements. An increase in nursing workload is also significantly associated with an increased incidence rate of nosocomial infections. The association between nursing workload in ICU patients and increased incidence rates of mortality is also supported by previous studies. The nurse-to-patient ratio has been previously used to evaluate patient safety correlation with the nursing workload as reported by previous reports. However, previous research shows that the nursing workload is a more complex correlation and can not be determined by a simple ratio as the nurse-to-patient one. Evidence shows that many adverse events may occur with patients in the ICU secondary to reduced nursing care such as increased mortality, length of hospital stay, and catching in-hospital infections. In the current study, we aim to review the outcomes from previous investigations to further emphasize the effect of nursing workload on ICU patient outcomes and safety.

Impact of Intensivist and Nursing Staff on Critically Ill Patient Mortality: A Retrospective Analysis of the Korean NHIS Cohort Data, 2011-2015

PURPOSE

Critical care medicine continues to evolve. However, critical care cases require increasing amount of medical resources. Intensive care unit (ICU) mortality significantly impacts the overall efficiency of healthcare resources within a system of limited medical resources. This study investigated the factors related to ICU mortality using long-term nationwide cohort data in South Korea.

MATERIALS AND METHODS

This retrospective cohort study used data of 14905721 patients who submitted reimbursement claims to the Korean Health Insurance Service between January 1, 2011 and December 31, 2015. A total of 1498102 patients who were admitted to all ICU types, except neonatal and long-term acute care hospitals, were enrolled.

RESULTS

Of the total 1498102 participants, 861397 (57.5%) were male and 636705 (42.5%) were female. The mean age at admission was 63.4±18.2 years; most of the subjects were aged over 60 years. During the 5-year period, in-hospital mortality rate was 12.9%. In Cox analysis, both in-hospital and 28-day mortality rates were significantly higher in male patients and those of lower socioeconomic status. As age increased and the number of nursing staff decreased, the mortality risk increased significantly by two or three times. The mortality risk was lower in patients admitted to an ICU of a tertiary university hospital and an ICU where intensivists worked.

CONCLUSION

The number of nursing staff and the presence of an intensivist in ICU were associated with the ICU mortality rate. Also, increasing the number of nursing staff and the presence of intensivist might reduce the mortality rate among ICU patients.