How to match supply and demand?

How to match supply and demand?

Bertrand GuidetMedical Intensive Care UnitParis , France

Supply ? Physicians Registered nurses (RN) Helpers Head nurse Other personnel

Respiratory therapist Pharmacist Clerks Psychologist

Demand ?

Patient treatment Administrative tasks Research Teaching Quality assessment?

Specificities ?

Type of hospital Type of ICU Case mix Seasons Crisis situation

Winter Terrorism Pandemia

Countries specificities ? Working rules ICU as part of a broader department Flexibility? Supplementary working hours Autonomy in decision making? Pool of nurses available in the

hospital? Interim agencies?

Shortage in trained Shortage in trained physicianphysicianss in ICU? in ICU?

Why fearing shortage in Europe? In the present time :

The trained ICU physicians are getting older There is a reduction in the working time

48 h a week No clinical activity after on night duty during a

11 h period In the future :

Reduction in the number of physicians Reluctance to choose CCM as a specialty :

To much work including nights duty Medico-legal issue

Is the question so simple?Is the question so simple? 1- What is an ICU ?1- What is an ICU ? 2- What is a trained ICU physician ?2- What is a trained ICU physician ? 3- What are ICU physicians supposed to do ?3- What are ICU physicians supposed to do ?

Job, tasks, duty, …..Job, tasks, duty, ….. 44- What is - What is the impact of the shortagethe impact of the shortage ? ? 5- Recommandations5- Recommandations

What is an ICU ?What is an ICU ?

An Official text has defined ICU in FranceOfficial text has defined ICU in France

« décret » April 5th 2002« décret » April 5th 2002 Minimum requirements :Minimum requirements :

- Number of beds : at least 8 - Number of beds : at least 8

- ICU director certified in intensive care medicine- ICU director certified in intensive care medicine

- Physician dedicated solely to the ICU during the - Physician dedicated solely to the ICU during the nightnight

- Non medical personnel :- Non medical personnel :

* Patients to nurses ratio : 2.5 / 1* Patients to nurses ratio : 2.5 / 1

* Patients to nurses’aides ratio : 4 / 1* Patients to nurses’aides ratio : 4 / 1

Other criteria Ability to provide :

Continuous monitoring Organ support : mechanical ventilation, dialysis

techniques, cardiovascular support,…. Proximity to other hospital units

Emergency room Operating room Radiology department

Description of the activity Severity scores Workload indexes Case mix

According to these criteria, at least 30% of existing ICU will close

in France in the next 5 years

What is the ICU’s contribution to the hospital activity ? Besides diagnosis and treatment of patients

admitted to the ICU To perform procedures for patients not

admitted in ICU Insertion of central venous line Dialysis Broncho alveolar lavage or transbronchial biopsy

for hypoxic patients. To evaluate patients for ICU admission

Ethical issue Clinical activity is not restricted to the

patients admitted in the ICU

What is a trained ICU physician ? What is a trained ICU physician ? Teaching of critical care in Europe Teaching of critical care in Europe The results ofThe results of 2 surveys 2 surveys

Garcia-Barbero. Crit Care Med 1996, 24 : 696Garcia-Barbero. Crit Care Med 1996, 24 : 696 No standardisation of curriculum contentNo standardisation of curriculum content No clear definition of competence (knowledge, No clear definition of competence (knowledge,

attitudes, skills, and judgement) necessary to practiceattitudes, skills, and judgement) necessary to practice littlelittle coordination of postgraduate training coordination of postgraduate training

Bion. Intensive care Med 1998, 24 : 372.Bion. Intensive care Med 1998, 24 : 372. Formal training in ICM : 18/21 countries (85%)Formal training in ICM : 18/21 countries (85%) Length of training : 18 to 30 months (median 24 Length of training : 18 to 30 months (median 24

months)months) Access to ICMAccess to ICM specialty specialty

Multidisciplinary : 57%Multidisciplinary : 57% Anaesthesia (28%)Anaesthesia (28%)

Accreditation in ICM : 18 countries Accreditation in ICM : 18 countries including 12including 12/18/18 with dual registration in a base with dual registration in a base

specialty and in ICM specialty and in ICM

Partial list of Partial list of trained physician activitiestrained physician activities

Coordination of patient careCoordination of patient care Continuous quality improvementContinuous quality improvement

CommitteesCommittees Morbidity and mortality reviewMorbidity and mortality review

Risk managementRisk management Safety netSafety net EducationEducation Medical consultant both formal and informalMedical consultant both formal and informal Medical-legal issuesMedical-legal issues Policy makerPolicy maker Epidemiology and infection controlEpidemiology and infection control Resource allocation (includes triage)Resource allocation (includes triage) ResearchResearch Conflict resolutionConflict resolution Technology assessmentTechnology assessment Computers/Medical information systemComputers/Medical information system

Health care policyHealth care policy Interhospital relations and planningInterhospital relations and planning Social services and coordinationSocial services and coordination Liaison withLiaison with

Hospital adminHospital adminisistrationtration Physician staffPhysician staff Nursing staffNursing staff Respiratory therapistRespiratory therapist LaboratoryLaboratory RadiologyRadiology Department of medicine, surgery, anaesthesiaDepartment of medicine, surgery, anaesthesia Clergy:pastoral careClergy:pastoral care

Self educationSelf education ResearchResearch TeachingTeaching …………....

And…And…

ScheduleSchedule of of French French ICU physiciansICU physiciansone week survey in 2002, 32 units including 13 teaching hospitalone week survey in 2002, 32 units including 13 teaching hospital

Type of activity Total Percentage Fellows Full time Dr Professor

Patient care 49 72 67 52 29ICU organisation 5 7 4 5 8Hospital organisation 4 6 1 4 7Self education 6 9 5 5 7Teaching 2 3 1 2 6Research 2 3 2 2 4Total (hours per week) 68 100 80 70 61

Organisational models of ICUsOrganisational models of ICUs

Organisational model :Organisational model : Open units : patients remains Open units : patients remains iin the service of the n the service of the

admitting physicianadmitting physician Closed units : medical director and designee screen all Closed units : medical director and designee screen all

admissions and discharges and assume direct patient admissions and discharges and assume direct patient care responscare responsiibilbiliitiesties

Closed units :Closed units : Reduction of LOS, morbidity and mortalityReduction of LOS, morbidity and mortality Requires more doctorsRequires more doctors

ExExaample of intensive mple of intensive communication intervention communication intervention Lilly, Am J Med 2000; 109 : 469Lilly, Am J Med 2000; 109 : 469

Method : multidisciplinary meetings held within 72 Method : multidisciplinary meetings held within 72 hours of critical care admission : patients, families, hours of critical care admission : patients, families, critical care team. + follow-up meetings to discuss critical care team. + follow-up meetings to discuss palliative care options when continued advanced palliative care options when continued advanced supportive technology supportive technology couldcould not achiev not achievee the the patient’s goal.patient’s goal.

The implementation of this active communication The implementation of this active communication hahass

reduced the median LOS (4 vs 3 days; p = 0.01) reduced the median LOS (4 vs 3 days; p = 0.01) while the mortality remained the same or even while the mortality remained the same or even

decreasedecreasedd

(31% vs 23%; p = 0.06).(31% vs 23%; p = 0.06).

Impact of organisational Impact of organisational characteristics of ICU to outcomecharacteristics of ICU to outcome

Pronovost , JAMA 1999, 281 : 1310Pronovost , JAMA 1999, 281 : 1310

Example of abdominal aortic surgery. Example of abdominal aortic surgery. Maryland hospitals; 1994-1996Maryland hospitals; 1994-1996 Measure of the impact of not having daily Measure of the impact of not having daily

roundsrounds

OR 95% CI

in-hospital mortality 3 [1.9-4.9]Risk of cardiac arrest 2.9 [1.2-7.0]acute renal failure 2.2 [1.3-3.9]septicemia 1.8 [1.2-2.6]platelet transfusion 6.4 [3.2-12.4]reintubation 2 [1-4.1]

Effect of a medical intensivist on patient care

Mathous Mayo Clin Proc 1997, 72 : 391

Full time medical intensivist no yes p

MICU mortality 20.9 14.9 0.02in-hospital mortality 34 24.6 0.002

Mean ICU LOS 5 3.9 <0.05Mean hospital LOS 22.6 17.7 <0.05

Resident test score 53.8% 67.5% <0.01

Factors that increase ICU resource Factors that increase ICU resource use after abdominal aortic surgery use after abdominal aortic surgery

Pronovost , JAMA 1999, 281 : 1310Pronovost , JAMA 1999, 281 : 1310

Not having daily roundsNot having daily rounds Having a nurse-patient ratio < 1:2Having a nurse-patient ratio < 1:2 Not having monthly review of Not having monthly review of

mortality and morbiditymortality and morbidity Extubating patients in the operating Extubating patients in the operating

roomroom

Relation between physician staffingRelation between physician staffing and performance and performance

Most of the sMost of the sttudies have focused onudies have focused on the the nurses and very nurses and very few have looked at the impact of the number or few have looked at the impact of the number or qualificationqualificationss of the physicians on outcomes. of the physicians on outcomes.

What is performance ?What is performance ? MortalityMortality MorbidityMorbidity LOSLOS Patient and family satisfactionPatient and family satisfaction Other physician satisfactionOther physician satisfaction Administration Administration …………..

Methodological limitations :Methodological limitations : Type of hospital and environmentType of hospital and environment Case mixCase mix Admission and discharge policyAdmission and discharge policy

In practice

What is the reality ?What are the proposals ?

Observations from the department of Veterans affairs’ ICU

Halpern Crit care Med 1994, 22 : 2008

MICU SICU Combined

ICU director Director assigned (%) 100 90 83 CCM training (%) 33 26 21 CCM board (%) 52 37 38

ICU attendings coverage 24h (%) 93 89 71 attending rounds (%) 91 76 60 Fellows assigned (%) 86 18 20

Medical staff of French ICUMedical staff of French ICUa 1999 survey of 174 unitsa 1999 survey of 174 units

Type of hospital Non teaching Teaching

ICU (n) 130 44Beds (n) 10.3 19.9LOS (days) 6.6 8.3Mechanical ventilation (%) 53 55

Full time physician (n) 2.7 3.3Part time (n) 0.1 0.7Fellows (n) 0.8 1.8Full time equivalent (n) 3.6 5.8FTE / bed 0.35 0.29

Residents (n) 0.9 3.1

Night dutiesNight dutiesType of hospital Non teaching Teaching

Type of night duties (%) On site (%) 91.5 100 For ICU solely (%) 71 84

Together with resident always (%) 14 47 sometimes (%) 16 32 never (%) 70 21

On calls (%) 27 34

Physicians on the list (%) n 7.6 10.5

% of Dr belonging to the ICU 59 66

Qualification of physicians (%) Medical doctors 95 88

CCM specialists 77 44

Critical care services and personnel : recommendations based on a system of categorization into two levels of careAmerican College of Critical Care Medicine of the SCCM. Crit Care Med 1999, 27 : 422

Medical staff organisation A distinct medical staff The team is organized and led by an intensivist Patient management is directed by an

attending physician who : Has clinical management responsibility Is board certified in CCM Sees the patients as often as required but at

least twice daily Participation in the institution’s bioethical

committee

Physician availability 24-hr in-house coverage

Non tertiary center : At least one physician who can manage emergencies. If this requirement is fulfilled by senior residents, an attending physician fully credentialed in CCM must be on call and available within 30 mins.

Tertiary center : Critical care physician is appropriately credentialed to provide dedicated care to the critical care unit patients: If this requirement is fulfilled by critical care fellows, a critical care staff physician must be on call and available within 30 mins.

The French model

Maximum working time per week : 48 h, including on nights duties.

Rest of at least 11 hours after on night duty Minimum requirements for a 10 beds unit :

3 physicians for morning 2 physicians for afternoon 1 physician for night

This requires 6.5 FTE per unit

Conclusion : unresolved issues

Impact of restructuration of the units Impact of creation of intermediate care units New organisation and management of the ICU Increase the attractiveness of this specialty Ethical issue – admission policy The expected shortage of ICU physicians will

increase the risk of lower quality of care No team building Lack of coherency in the clinical management of patients No involvement outside the unit No research and teaching

Recommendation for RN?

Stratification in three levels of care Level 1 : 1 RN for 1 patient Level 2 : 1 RN for 2 patients Level 3 : 1 RN for 4 patients

In France and at the bed side 1 RN for 2.5 patients 1 Helper for 4 patients

Adaptation according to work load

Measure of work load Tiss, PRN, NEMS,…

Inclusion of new tasks Paper work Communication Quality assessment

Time frame?

Short range Phone call 2 hours prior to the working

shift? Long range

Discrepancies between supply and demand

Short range

Ability to mobilize RN Same unit Other units

Stop admission for this shift

Long range

Definition of norms and standard Country level European recommendations?

Type of norms : Quantitative & qualitative

Ratio RN/patient Basic training of RN Continuous education

What happen if these recommendations are not fulfilled?

Reduction of the number of beds Impact for the non admitted patients? Regional regulation Number of ICU beds/100,000 inhabitants

Increase of work load for each individual RN Impact on quality of care Nosocomial infection Burn out and turn over Weaning procedures

Analysis of the work flow according to type of ICU

Surgical ICU with scheduled surgery Less RN in morning shift Less RN during week end

Tertiary center Polytrauma center

Is it possible to predict activity?

MODELS FOR FORECASTING THE NUMBER OF EMERGENCY DEPARTMENT VISITS Wargon M, …. Guidet B. Emergency Med J (in press).

We reviewed articles retrieved by a Medline search for studies of models designed to predict patient attendance in EDs or walk-in clinics.

Only 9 studies were identified. Most of the models used to predict patient volume

were either linear regression models including calendar variables or time series models. These models explained 31% to 75% of patient-volume variability.

Although day of the week had the strongest effect on patient volume, this variable explained only part of the variability, whose causes remained largely unidentified. Adding meteorological data failed to improve model performance.

Numer of patients attending one specific ED : Real figures

Predicted versus observed ED visits in 4 hospitals

300

350

400

450

500

550

Jan-04

Feb-04

Mar-0

4

Apr-04

May-0

4

Jun-04

Jul-04

Aug-04

Sep-04

Oct-0

4

Nov-04

Dec-04

Jan-05

Feb-05

Mar-0

5

Apr-05

May-0

5

Jun-05

Jul-05

Aug-05

Sep-05

Oct-0

5

Nov-05

Dec-05

DATE by day

vis

its

pe

r d

ay

Actual

Model

Identification of variables influencing ED visits

p=0.019p = 0.00p= 0.005p= 0.0000.631All 4 EDs

p=0.033p = 0.02p= 0.551p= 0.0000.433N°4

p=0.002p=0.000p= 0.012p= 0.0010.471N°3

p=0.0712p=0.000p=0.003p=0.0810.433N°2

p= 0. 394p=0.008p=0.280p= 0.0000.461N°1

school holidays

months Official holiday

Day of week

R2Hospital

ModelParameter

values

1. Original signal: observed patient visits

Forecastedset withthe model

Trainingset

Validation set

Validationset

2. estimation of the parametervalues in the model

3. model evaluation

Training set

Best fitPerformanceevaluation

Construction and validation of the model

Organization of intensive care units, in case of pandemic avian flu. Guery B, Guidet B Rev Mal Respir. 2008;25: 223-35.

Working hypothesis ICU should be expended twice its capacity Only one third of the nurses will at work

Sick themselves Children sick Transportation difficulties Nursery closed Schools closed

High work load per patient High incidence of ARDS Individual protection in order to prevent

contamination

Proposal in case of pandemic avian flu. Guery B, Guidet B Rev Mal Respir. 2008;25: 223-35.

Reduction of scheduled hospital activities in particular for surgery enabling mobilization of personnel working in this sector to the ICU

Allowing nurses without expertise in ICU to work with ICU nurses with a ratio 1/1.

Dedicated personnel to handle communication with the relatives, the administration, the media…

Ethical issues Admission policy Decision to withdraw or withheld treatment

Importance of management skills and organisation

Relation between organizational score and work loadAssessing organizational performance in ICU’s: A French experience. Minvielle E, …, Guidet B. J Crit Care 2008, 23:236-244

26 ICUs located in the Paris area, France Data were collected through answers of 1000 ICU

personnel to COMIC questionnaire and from the database.

Organizational Performance was assessed through a composite score related to five dimensions: Coordination and adaptation to uncertainty, Communication, Conflict Management, Organizational change and Organizational

Learning, Skills developed in relationship with patients and

their families.

Methods

ORGANIZATIONAL PERFORMANCE

Organizational learning and change

Communication

Coordination

Problem-solving/conflict management

Skills developed in the relation patient/caregivers

The effect of Individual and ICU level factors on Organizational performance using Hierarchical Modelling.

Effect Estimate SE p-value

Parameters

Intercept 6.65 1.37 <.0001

Lack of burn-out 0.03 0.006 <.0001

Satisfaction at work 0.41 0.06 <.0001

Age 0.03 0.01 0.0172

Physician and nurse / bed 0.84 0.22 0.0001

Workload / day 0.21 0.09 0.0185

Variances

ICU level 0.39 0.18 0.0135

Individual level 3.80 0.24 <.0001

Relations between perceived Relations between perceived workload-burnout and performanceworkload-burnout and performance

Euricus I study (n=2009 questionnaires)Euricus I study (n=2009 questionnaires)

PWLPWL EEEE DPDP PUPPUP

PWL : perceived workloadEE : emotional exhaustionDP : depersonalizationPUP : perceived unit performance

.70***.70*** .54***.54*** -.17***-.17***

-.19***-.19***

Relations between observed Relations between observed workload-burnout and performanceworkload-burnout and performance

NEMSNEMS EEEE DPDP OUPOUP.19*.19* .62***.62*** -.09-.09

-.10-.10

NEMS : nine equivalents manpowerEE : emotional exhaustionDP : depersonalizationOUP : objective unit performance

Why is there such discrepancies between perceived and observed results ?

WorkloadWorkload BurnoutBurnout PerformancePerformance

CopingCopingresourcesresources

InvolvementInvolvement

Goals of collaboration Goals of collaboration in in team buildingteam building

To provide superior patient care by combining the To provide superior patient care by combining the unique expertise of all professionsunique expertise of all professions

To maximize productivityTo maximize productivity,, effective and efficient use of effective and efficient use of the the personnelpersonnel

To enhance professional development and satisfaction, To enhance professional development and satisfaction, thereby improving staff retentionthereby improving staff retention

To promote interprofessional cohesivenessTo promote interprofessional cohesiveness To clarify the interactive roles with other professionalsTo clarify the interactive roles with other professionals To foster communication, collegiality, respect, and To foster communication, collegiality, respect, and

understanding among the professions.understanding among the professions.

In case of mismatch between supply and demand.

Increase the supply : more nurses Decrease the demand Motivation of personnel : team building Mobilisation of personnel from outside

the ICU Organisational issues with other health

care workers contributing to cope with the work load in the iCU